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Belli T, de Macedo DV, Scariot PPM, de Araújo GG, Dos Reis IGM, Lazarim FL, Nunes LAS, Brenzikofer R, Gobatto CA. Glycemic Control and Muscle Damage in 3 Athletes With Type 1 Diabetes During a Successful Performance in a Relay Ultramarathon: A Case Report. Wilderness Environ Med 2017. [PMID: 28629959 DOI: 10.1016/j.wem.2017.04.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Ultramarathon races are fairly demanding and impose substantial physiological stress on healthy athletes. These competitions may thus be considerably more challenging for individuals with diabetes. This case study aims to describe glycemic control, muscle damage, inflammation, and renal function in 3 athletes with type 1 diabetes during a successful performance in a relay ultramarathon. The team completed the race in 29 hours and 28 minutes, earning third place. The total distance covered by each athlete was 68.7, 84.5, and 65.1 km. Most blood glucose levels showed that athletes were in a zone where it was safe to exercise (90-250 mg/dL or 5.0-13.9 mmol/L). Creatine kinase, lactate dehydrogenase, and aspartate aminotransferase serum levels increased 1.2- to 50.7-fold prerace to postrace, and were higher than the reference ranges for all the athletes postrace. Blood leukocytes, neutrophils, and serum C-reactive protein (CRP) increased 1.6- to 52-fold prerace to postrace and were higher than the reference ranges for 2 athletes after the race. Serum creatinine increased 1.2-fold prerace to postrace for all the athletes but did not meet the risk criteria for acute kidney injury. In conclusion, our main findings show evidence of satisfactory glycemic control in athletes with type 1 diabetes during a relay ultramarathon. Moreover, elevation of muscle damage and inflammatory biomarkers occurred without affecting renal function and challenging the maintenance of blood glucose among athletes. These findings are novel and provide an initial understanding of the physiological responses in athletes with type 1 diabetes during ultramarathon races.
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Affiliation(s)
- Taisa Belli
- Laboratory of Applied Sport Physiology (LAFAE), School of Applied Sciences, University of Campinas, Limeira, SP, Brazil (Dr Belli, Mr Scariot, Drs dos Reis and Gobatto)
| | - Denise V de Macedo
- Laboratory of Exercise Biochemistry (LABEX), Biochemistry Department, Biology Institute, University of Campinas, Campinas, SP, Brazil (Drs de Macedo, Lazarim, and Nunes)
| | - Pedro P M Scariot
- Laboratory of Applied Sport Physiology (LAFAE), School of Applied Sciences, University of Campinas, Limeira, SP, Brazil (Dr Belli, Mr Scariot, Drs dos Reis and Gobatto)
| | - Gustavo G de Araújo
- Sports Science Research Group - Federal University of Alagoas (UFAL), Maceio AL, Brazil (Dr de Araújo)
| | - Ivan G M Dos Reis
- Laboratory of Applied Sport Physiology (LAFAE), School of Applied Sciences, University of Campinas, Limeira, SP, Brazil (Dr Belli, Mr Scariot, Drs dos Reis and Gobatto)
| | - Fernanda L Lazarim
- Laboratory of Exercise Biochemistry (LABEX), Biochemistry Department, Biology Institute, University of Campinas, Campinas, SP, Brazil (Drs de Macedo, Lazarim, and Nunes)
| | - Lázaro A S Nunes
- Laboratory of Exercise Biochemistry (LABEX), Biochemistry Department, Biology Institute, University of Campinas, Campinas, SP, Brazil (Drs de Macedo, Lazarim, and Nunes)
| | - René Brenzikofer
- Laboratory of Instrumentation for Biomechanics (LIB), Faculty of Physical Education, University of Campinas, Campinas, SP, Brazil (Dr Brenzikofer)
| | - Claudio A Gobatto
- Laboratory of Applied Sport Physiology (LAFAE), School of Applied Sciences, University of Campinas, Limeira, SP, Brazil (Dr Belli, Mr Scariot, Drs dos Reis and Gobatto).
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1352
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Biswas A, Faulkner GE, Oh PI, Alter DA. Patient and practitioner perspectives on reducing sedentary behavior at an exercise-based cardiac rehabilitation program. Disabil Rehabil 2017; 40:2267-2274. [PMID: 28583032 DOI: 10.1080/09638288.2017.1334232] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PURPOSE To understand the awareness of sedentary behavior, as well as the perceived facilitators and barriers to reducing sedentary behaviors from the perspectives of patients undertaking an exercise-based cardiac rehabilitation program, and from staff involved in supporting patient self-management. MATERIALS AND METHODS A qualitative study was conducted at a large cardiac rehabilitation program in a metropolitan city in Canada. Guided by an ecological framework, semi-structured interviews were conducted individually with 15 patients, and in two focus groups with six staff. Transcribed interviews were analyzed by thematic analysis. RESULTS Patients placed little importance on reducing sedentary behavior as they were unconvinced of the health benefits, did not perceive themselves to be sedentary, or associated such behaviors with enjoyment and relaxation. While staff were aware of the risks, they saw them as less critical than other health behaviors. Intrapersonal factors (physical and psychosocial health) and environment factors (the information environment, socio-cultural factors) within leisure time, the home, and work, influenced sedentary behavior. CONCLUSIONS While these findings require further testing, future interventions may be effective if aimed at increasing awareness of the health benefits of reducing sedentary behavior, utilizing existing behavior change strategies, and using a participatory approach to tailor strategies to patients. Implications for rehabilitation Cardiac rehabilitation programs effectively use exercise promotion to improve the health of people with established cardiovascular disease. As sedentary lifestyles become more prevalent, recommendations to reduce the health risks of prolonged sedentary behavior that are specific to the characteristics and prognostic profiles of cardiac rehabilitation patients are needed. Cardiac rehabilitation programs must consider extending existing behavior change strategies utilized for exercise promotion towards addressing sedentary behaviors in order to be effective at reducing the sedentary time of patients. A participatory approach involving both patients and health professionals can support patients in reducing their sedentary behavior by providing a supportive environment for behavior change, increasing awareness and understanding of risks, discussing the feasibility of potential strategies, and setting achievable and actionable goals.
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Affiliation(s)
- Aviroop Biswas
- a Institute of Health Policy, Management & Evaluation , University of Toronto , Toronto , Canada
| | - Guy E Faulkner
- b School of Kinesiology , University of British Columbia , Vancouver , Canada
| | - Paul I Oh
- c University Health Network, Toronto Rehabilitation Institute , Toronto , Canada
| | - David A Alter
- c University Health Network, Toronto Rehabilitation Institute , Toronto , Canada
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1353
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Zaharieva D, Yavelberg L, Jamnik V, Cinar A, Turksoy K, Riddell MC. The Effects of Basal Insulin Suspension at the Start of Exercise on Blood Glucose Levels During Continuous Versus Circuit-Based Exercise in Individuals with Type 1 Diabetes on Continuous Subcutaneous Insulin Infusion. Diabetes Technol Ther 2017; 19:370-378. [PMID: 28613947 PMCID: PMC5510047 DOI: 10.1089/dia.2017.0010] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Exercise causes glycemic disturbances in individuals with type 1 diabetes (T1D). Continuous moderate-intensity aerobic exercise (CON) generally lowers blood glucose (BG) levels and often leads to hypoglycemia. In comparison, circuit-based exercise (CIRC) may attenuate the drop in BG. The goal of this study is to contrast the effects of basal insulin suspension at the onset of two different forms of exercise (CON vs. CIRC). METHODS Twelve individuals (six men and six women) with T1D on insulin pump therapy were recruited for the study. All participants completed a maximal aerobic fitness test and two 40-min exercise sessions, consisting of either continuous treadmill walking or a circuit workout. Basal insulin infusion was stopped at the onset of exercise and resumed in recovery. After providing an initial reference value, volunteers were blinded to their [BG] and were asked to estimate their levels during exercise. RESULTS Oxygen consumption (47.5 ± 7.5 vs. 54.5 ± 13.5 mL·kg-1·min-1, P = 0.03) and heart rate (122 ± 20 vs. 144 ± 20 bpm, P = 0.003) were lower in CON vs. CIRC. Despite the lower workload, BG levels dropped more with CON vs. CIRC (delta BG = -3.8 ± 1.5 vs. -0.5 ± 3.0 mmol/L for CON vs. CIRC, respectively, P = 0.001). Participants were able to estimate their BG more accurately during CON (r = 0.83) vs. CIRC (r = 0.33) based on a regression analysis. CONCLUSION Despite a lower intensity of exercise, with full basal insulin suspension at the start of exercise, CON results in a larger drop in BG vs. CIRC. These findings have implications for single hormone-based artificial pancreas development for exercise. While this study does not negate the importance of frequent capillary BG monitoring during exercise, it does suggest that if persons are knowledgeable about their pre-exercise BG levels, they can accurately perceive the changes in BG during CON, but not during CIRC.
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Affiliation(s)
- Dessi Zaharieva
- School of Kinesiology and Health Science, Faculty of Health, Muscle Health Research Centre and Physical Activity and Chronic Disease Unit, York University, Toronto, Canada
| | - Loren Yavelberg
- School of Kinesiology and Health Science, Faculty of Health, Muscle Health Research Centre and Physical Activity and Chronic Disease Unit, York University, Toronto, Canada
| | - Veronica Jamnik
- School of Kinesiology and Health Science, Faculty of Health, Muscle Health Research Centre and Physical Activity and Chronic Disease Unit, York University, Toronto, Canada
| | - Ali Cinar
- Department of Biomedical Engineering, Illinois Institute of Technology, Chicago, Illinois
- Chemical and Biological Engineering, Illinois Institute of Technology, Chicago, Illinois
| | - Kamuran Turksoy
- Department of Biomedical Engineering, Illinois Institute of Technology, Chicago, Illinois
| | - Michael C. Riddell
- School of Kinesiology and Health Science, Faculty of Health, Muscle Health Research Centre and Physical Activity and Chronic Disease Unit, York University, Toronto, Canada
- LMC Diabetes & Endocrinology, Toronto, Canada
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1354
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Huyett LM, Ly TT, Forlenza GP, Reuschel-DiVirgilio S, Messer LH, Wadwa RP, Gondhalekar R, Doyle FJ, Pinsker JE, Maahs DM, Buckingham BA, Dassau E. Outpatient Closed-Loop Control with Unannounced Moderate Exercise in Adolescents Using Zone Model Predictive Control. Diabetes Technol Ther 2017; 19:331-339. [PMID: 28459617 PMCID: PMC5510043 DOI: 10.1089/dia.2016.0399] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND The artificial pancreas (AP) has the potential to improve glycemic control in adolescents. This article presents the first evaluation in adolescents of the Zone Model Predictive Control and Health Monitoring System (ZMPC+HMS) AP algorithms, and their first evaluation in a supervised outpatient setting with frequent exercise. MATERIALS AND METHODS Adolescents with type 1 diabetes underwent 3 days of closed-loop control (CLC) in a hotel setting with the ZMPC+HMS algorithms on the Diabetes Assistant platform. Subjects engaged in twice-daily exercise, including soccer, tennis, and bicycling. Meal size (unrestricted) was estimated and entered into the system by subjects to trigger a bolus, but exercise was not announced. RESULTS Ten adolescents (11.9-17.7 years) completed 72 h of CLC, with data on 95 ± 14 h of sensor-augmented pump (SAP) therapy before CLC as a comparison to usual therapy. The percentage of time with continuous glucose monitor (CGM) 70-180 mg/dL was 71% ± 10% during CLC, compared to 57% ± 16% during SAP (P = 0.012). Nocturnal control during CLC was safe, with 0% (0%, 0.6%) of time with CGM <70 mg/dL compared to 1.1% (0.0%, 14%) during SAP. Despite large meals (estimated up to 120 g carbohydrate), only 8.0% ± 6.9% of time during CLC was spent with CGM >250 mg/dL (16% ± 14% during SAP). The system remained connected in CLC for 97% ± 2% of the total study time. No adverse events or severe hypoglycemia occurred. CONCLUSIONS The use of the ZMPC+HMS algorithms is feasible in the adolescent outpatient environment and achieved significantly more time in the desired glycemic range than SAP in the face of unannounced exercise and large announced meal challenges.
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Affiliation(s)
- Lauren M. Huyett
- Department of Chemical Engineering, University of California Santa Barbara, Santa Barbara, California
- William Sansum Diabetes Center, Santa Barbara, California
| | - Trang T. Ly
- Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University, Stanford, California
| | - Gregory P. Forlenza
- Barbara Davis Center for Childhood Diabetes, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Suzette Reuschel-DiVirgilio
- Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University, Stanford, California
| | - Laurel H. Messer
- Barbara Davis Center for Childhood Diabetes, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - R. Paul Wadwa
- Barbara Davis Center for Childhood Diabetes, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Ravi Gondhalekar
- William Sansum Diabetes Center, Santa Barbara, California
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, Massachusetts
| | - Francis J. Doyle
- Department of Chemical Engineering, University of California Santa Barbara, Santa Barbara, California
- William Sansum Diabetes Center, Santa Barbara, California
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, Massachusetts
| | | | - David M. Maahs
- Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University, Stanford, California
- Barbara Davis Center for Childhood Diabetes, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Bruce A. Buckingham
- Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University, Stanford, California
| | - Eyal Dassau
- Department of Chemical Engineering, University of California Santa Barbara, Santa Barbara, California
- William Sansum Diabetes Center, Santa Barbara, California
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, Massachusetts
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1355
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Pinto AJ, Roschel H, de Sá Pinto AL, Lima FR, Pereira RMR, Silva CA, Bonfá E, Gualano B. Physical inactivity and sedentary behavior: Overlooked risk factors in autoimmune rheumatic diseases? Autoimmun Rev 2017; 16:667-674. [PMID: 28479487 DOI: 10.1016/j.autrev.2017.05.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 03/15/2017] [Indexed: 12/17/2022]
Abstract
This review aims to (1) summarize the estimates of physical inactivity and sedentary behavior in autoimmune rheumatic diseases; (2) describe the relationship between physical (in)activity levels and disease-related outcomes; (3) contextualize the estimates and impact of physical inactivity and sedentary behavior in autoimmune diseases compared to other rheumatic diseases and chronic conditions; and (4) discuss scientific perspectives around this theme and potential clinical interventions to attenuate these preventable risk factors. We compiled evidence to show that estimates of physical inactivity and sedentary behavior in autoimmune rheumatic diseases are generally comparable to other rheumatic diseases as well as to other chronic conditions (e.g., type 2 diabetes, cardiovascular diseases, and obesity), in which a lack of physical activity and excess of sedentary behavior are well-known predictors of morbimortality. In addition, we also showed evidence that both physical inactivity and sedentary behavior may be associated with poor health-related outcomes (e.g., worse disease symptoms and low functionality) in autoimmune rheumatic diseases. Thus, putting into practice interventions to make the patients "sit less and move more", particularly light-intensity activities and/or breaking-up sedentary time, is a simple and prudent therapeutic approach to minimize physical inactivity and sedentary behavior, which are overlooked yet modifiable risk factors in the field of autoimmune rheumatic diseases.
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Affiliation(s)
- Ana Jéssica Pinto
- Applied Physiology and Nutrition Research Group, Universidade de Sao Paulo, Av. Professor Mello Moraes, 65 - Cidade Universitaria, Sao Paulo/SP 05508-030, Brazil; Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Rua Dr. Ovídio Pires de Campos, 225 - Cerqueira Cesar, Sao Paulo/SP 05403-010, Brazil.
| | - Hamilton Roschel
- Applied Physiology and Nutrition Research Group, Universidade de Sao Paulo, Av. Professor Mello Moraes, 65 - Cidade Universitaria, Sao Paulo/SP 05508-030, Brazil; Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Rua Dr. Ovídio Pires de Campos, 225 - Cerqueira Cesar, Sao Paulo/SP 05403-010, Brazil.
| | - Ana Lúcia de Sá Pinto
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Rua Dr. Ovídio Pires de Campos, 225 - Cerqueira Cesar, Sao Paulo/SP 05403-010, Brazil.
| | - Fernanda Rodrigues Lima
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Rua Dr. Ovídio Pires de Campos, 225 - Cerqueira Cesar, Sao Paulo/SP 05403-010, Brazil.
| | - Rosa Maria Rodrigues Pereira
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Rua Dr. Ovídio Pires de Campos, 225 - Cerqueira Cesar, Sao Paulo/SP 05403-010, Brazil.
| | - Clovis Artur Silva
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Rua Dr. Ovídio Pires de Campos, 225 - Cerqueira Cesar, Sao Paulo/SP 05403-010, Brazil.
| | - Eloisa Bonfá
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Rua Dr. Ovídio Pires de Campos, 225 - Cerqueira Cesar, Sao Paulo/SP 05403-010, Brazil.
| | - Bruno Gualano
- Applied Physiology and Nutrition Research Group, Universidade de Sao Paulo, Av. Professor Mello Moraes, 65 - Cidade Universitaria, Sao Paulo/SP 05508-030, Brazil; Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Rua Dr. Ovídio Pires de Campos, 225 - Cerqueira Cesar, Sao Paulo/SP 05403-010, Brazil.
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1356
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Riddell MC, Gallen IW, Smart CE, Taplin CE, Adolfsson P, Lumb AN, Kowalski A, Rabasa-Lhoret R, McCrimmon RJ, Hume C, Annan F, Fournier PA, Graham C, Bode B, Galassetti P, Jones TW, Millán IS, Heise T, Peters AL, Petz A, Laffel LM. Exercise management in type 1 diabetes: a consensus statement. Lancet Diabetes Endocrinol 2017; 5:377-390. [PMID: 28126459 DOI: 10.1016/s2213-8587(17)30014-1] [Citation(s) in RCA: 488] [Impact Index Per Article: 69.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Revised: 11/20/2016] [Accepted: 11/21/2016] [Indexed: 12/28/2022]
Abstract
Type 1 diabetes is a challenging condition to manage for various physiological and behavioural reasons. Regular exercise is important, but management of different forms of physical activity is particularly difficult for both the individual with type 1 diabetes and the health-care provider. People with type 1 diabetes tend to be at least as inactive as the general population, with a large percentage of individuals not maintaining a healthy body mass nor achieving the minimum amount of moderate to vigorous aerobic activity per week. Regular exercise can improve health and wellbeing, and can help individuals to achieve their target lipid profile, body composition, and fitness and glycaemic goals. However, several additional barriers to exercise can exist for a person with diabetes, including fear of hypoglycaemia, loss of glycaemic control, and inadequate knowledge around exercise management. This Review provides an up-to-date consensus on exercise management for individuals with type 1 diabetes who exercise regularly, including glucose targets for safe and effective exercise, and nutritional and insulin dose adjustments to protect against exercise-related glucose excursions.
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Affiliation(s)
- Michael C Riddell
- Muscle Health Research Centre, York University, Toronto, ON, Canada.
| | - Ian W Gallen
- Royal Berkshire NHS Foundation Trust Centre for Diabetes and Endocrinology, Royal Berkshire Hospital, Reading, UK
| | - Carmel E Smart
- Hunter Medical Research Institute, School of Health Sciences, University of Newcastle, Rankin Park, NSW, Australia
| | - Craig E Taplin
- Division of Endocrinology and Diabetes, Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, WA, USA
| | - Peter Adolfsson
- Department of Pediatrics, The Hospital of Halland, Kungsbacka, Sweden; Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Alistair N Lumb
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, UK
| | - Aaron Kowalski
- Juvenile Diabetes Research Foundation, New York, NY, USA
| | - Remi Rabasa-Lhoret
- Department of Nutrition and Institut de Recherches Cliniques de Montréal, Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Rory J McCrimmon
- Division of Molecular and Clinical Medicine, School of Medicine, University of Dundee, Dundee, UK
| | | | - Francesca Annan
- Children and Young People's Diabetes Service, University College London Hospitals NHS Foundation Trust, London, UK
| | - Paul A Fournier
- School of Sport Science, Exercise, and Health, Perth, WA, Australia
| | | | - Bruce Bode
- Atlanta Diabetes Associates, Atlanta, GA, USA
| | - Pietro Galassetti
- Department of Pediatrics, University of California Irvine, Irvine, CA, USA; AstraZeneca, Gaithersburg, MD, USA
| | - Timothy W Jones
- The University of Western Australia, Perth, WA, Australia; Department of Endocrinology and Diabetes, Princess Margaret Hospital for Children, Perth, WA, Australia; Telethon Kids Institute, Perth, WA, Australia
| | - Iñigo San Millán
- Department of Physical Medicine and Rehabilitation, University of Colorado, School of Medicine, Aurora, CO, USA
| | | | - Anne L Peters
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | | | - Lori M Laffel
- Division of Endocrinology, Boston Children's Hospital, Boston, MA, USA; Pediatric, Adolescent and Young Adult Section, Joslin Diabetes Center, Boston, MA, USA
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1357
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Affiliation(s)
| | - Eyal Dassau
- 1 William Sansum Diabetes Center , Santa Barbara, California
- 2 Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University , Cambridge, Massachusetts
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1358
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Berg EG. Lessons in Care: Insights Into Recent Changes in the American Diabetes Association's Clinical Practice Recommendations. Clin Diabetes 2017; 35:96-99. [PMID: 28442824 PMCID: PMC5391817 DOI: 10.2337/cd17-0012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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1359
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A pilot study of short-term toe resistance training in patients with type 2 diabetes mellitus. Diabetol Int 2017; 8:392-396. [PMID: 30603345 DOI: 10.1007/s13340-017-0318-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Accepted: 03/22/2017] [Indexed: 12/25/2022]
Abstract
Objective The purpose of this pilot study was to investigate the effect of short-term toe resistance training on toe pinch force and toe muscle quality in patients with type 2 diabetes mellitus. Methods A total of 12 patients with type 2 diabetes mellitus who were hospitalized to improve glycemic control (8 men and 4 women, duration of diabetes 12.2 ± 9.5 years) were enrolled in this pilot study. Exercise therapy was performed with conventional aerobic exercise and four newly developed toe resistance training exercises for 2 weeks. Changes in anthropometric parameters, blood pressure (BP), heart rate, and muscle parameters, i.e. muscle mass, toe pinch force and toe muscle quality were evaluated after the exercise program. Results There were no significant differences of body weight, body mass index, BP, heart rate, and upper/lower muscle mass after exercise performance. However, toe pinch force was significantly increased (pre: 2.92 ± 1.19 kg, post: 3.65 ± 1.58 kg, p = 0.007). Toe muscle quality (toe pinch force/lower leg muscle mass) were also significantly increased (pre: 2.15 ± 0.86 kg/kg, post: 2.72 ± 1.26 kg/kg, p = 0.009). Conclusions Two weeks of toe resistance training significantly increased toe pinch force and toe muscle quality in patients with type 2 diabetes mellitus. Toe resistance training is might be essential for treating patients with diabetes mellitus in clinical practice.
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1360
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Pesta DH, Goncalves RLS, Madiraju AK, Strasser B, Sparks LM. Resistance training to improve type 2 diabetes: working toward a prescription for the future. Nutr Metab (Lond) 2017; 14:24. [PMID: 28270856 PMCID: PMC5335813 DOI: 10.1186/s12986-017-0173-7] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 02/14/2017] [Indexed: 01/07/2023] Open
Abstract
The prevalence of type 2 diabetes (T2D) is rapidly increasing, and effective strategies to manage and prevent this disease are urgently needed. Resistance training (RT) promotes health benefits through increased skeletal muscle mass and qualitative adaptations, such as enhanced glucose transport and mitochondrial oxidative capacity. In particular, mitochondrial adaptations triggered by RT provide evidence for this type of exercise as a feasible lifestyle recommendation to combat T2D, a disease typically characterized by altered muscle mitochondrial function. Recently, the synergistic and antagonistic effects of combined training and Metformin use have come into question and warrant more in-depth prospective investigations. In the future, clinical intervention studies should elucidate the mechanisms driving RT-mitigated mitochondrial adaptations in muscle and their link to improvements in glycemic control, cholesterol metabolism and other cardiovascular disease risk factors in individuals with T2D.
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Affiliation(s)
- Dominik H Pesta
- Department of Sport Science, Medical Section, University of Innsbruck, Fürstenweg 185, Innsbruck, Austria.,Department of Visceral, Transplant, and Thoracic Surgery, D. Swarovski Research Laboratory, Medical University of Innsbruck, Innsbruck, Austria.,Institute for Clinical Diabetology, German Diabetes Center, Leibniz Institute for Diabetes Research at Heinrich Heine University, Düsseldorf, Germany.,German Center for Diabetes Research (DZD e.V.), München-Neuherberg, Germany
| | - Renata L S Goncalves
- Department of Genetics and Complex Diseases and Sabri Ülker Center, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA 02115 USA
| | - Anila K Madiraju
- Salk Institute for Biological Studies, 10010N Torrey Pines Rd, La Jolla, CA 92037 USA
| | - Barbara Strasser
- Biocenter, Medical University Innsbruck, Innrain 80-82, Innsbruck, Austria
| | - Lauren M Sparks
- Translational Research Institute for Metabolism and Diabetes, Florida Hospital, 301 E. Princeton Street, Orlando, FL 32804 USA.,Sanford Burnham Prebys Medical Discovery Institute, Center for Clinical and Molecular Origins of Disease, Orlando, FL USA
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1361
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Fan W. Epidemiology in diabetes mellitus and cardiovascular disease. Cardiovasc Endocrinol 2017; 6:8-16. [PMID: 31646113 PMCID: PMC6768526 DOI: 10.1097/xce.0000000000000116] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 01/17/2017] [Indexed: 12/13/2022] Open
Abstract
As one of the leading causes of death in the USA, diabetes mellitus (DM) has become an epidemic over the past few decades. Despite the high prevalence of diagnosed DM, close to half of all people with DM are unaware of their disease. The risk of type 2 DM is determined by interplay of genetic and metabolic factors. Patients with type 2 DM have a higher risk of death from cardiovascular causes compared with their nondiabetic counterparts, and the mortality rate of DM associated cardiovascular disease is different among ethnicity groups and sex groups. Because of its adverse effect on people's health, DM also imposes an economic burden on individuals and households affected, as well as on the healthcare system. Current guidelines for cardiovascular disease prevention have focused on lifestyle management, blood pressure control, lipid control, blood glucose control, antiplatelet agent use, and tobacco use cessation.
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Affiliation(s)
- Wenjun Fan
- Department of Medicine, Heart Disease Prevention Program, Division of Cardiology, University of California, Irvine, California, USA
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1362
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Dempsey PC, Grace MS, Dunstan DW. Adding exercise or subtracting sitting time for glycaemic control: where do we stand? Diabetologia 2017; 60:390-394. [PMID: 27957594 DOI: 10.1007/s00125-016-4180-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Accepted: 11/29/2016] [Indexed: 02/02/2023]
Abstract
While regular structured exercise is a well-established (though arguably under-utilised) cornerstone in the prevention and management of type 2 diabetes, population adherence to recommended exercise guidelines remains stubbornly low. Indeed, most adults are exposed to environmental settings (at work, in automobile travel and in the domestic environment) that may not only limit their physical activity, but also promote sitting for prolonged periods of time. However, recent experimental evidence indicates that reducing and breaking up sitting time may also be a useful strategy to improve glycaemic control. In this issue of Diabetologia, Duvivier and colleagues report findings which suggest that reducing sitting time with standing and light-intensity activity could be a potential alternative to structured exercise for improving glycaemic control in type 2 diabetes patients. We review and discuss the findings of this study, its potential clinical implications, and a number of knowledge gaps and opportunities that could be considered in the interest of future research. The findings from Duvivier and colleagues should encourage healthcare practitioners, researchers and type 2 diabetes patients to consider the whole spectrum of physical activity, from sedentary behaviour through to structured exercise.
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Affiliation(s)
- Paddy C Dempsey
- Baker IDI Heart and Diabetes Institute, Level 4, 99 Commercial Rd, Melbourne, VIC, 3004, Australia.
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia.
| | - Megan S Grace
- Baker IDI Heart and Diabetes Institute, Level 4, 99 Commercial Rd, Melbourne, VIC, 3004, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
- School of Health and Biomedical Sciences, RMIT University, Bundoora, VIC, Australia
| | - David W Dunstan
- Baker IDI Heart and Diabetes Institute, Level 4, 99 Commercial Rd, Melbourne, VIC, 3004, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
- Institute of Physical Activity and Nutrition Research, School of Exercise and Nutrition Sciences, Deakin University, Melbourne, VIC, Australia
- School of Sport Science, Exercise and Health, The University of Western Australia, Perth, WA, Australia
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, VIC, Australia
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1363
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Colberg SR. Key Points from the Updated Guidelines on Exercise and Diabetes. Front Endocrinol (Lausanne) 2017; 8:33. [PMID: 28265261 PMCID: PMC5317029 DOI: 10.3389/fendo.2017.00033] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2017] [Accepted: 02/07/2017] [Indexed: 12/27/2022] Open
Affiliation(s)
- Sheri R. Colberg
- Human Movement Sciences Department, Old Dominion University, Norfolk, VA, USA
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1364
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McCarthy MM, Whittemore R, Gholson G, Grey M. Self-management of physical activity in adults with type 1 diabetes. Appl Nurs Res 2017; 35:18-23. [PMID: 28532721 DOI: 10.1016/j.apnr.2017.02.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Accepted: 02/01/2017] [Indexed: 12/18/2022]
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1365
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Eshghi SR, Fletcher K, Myette-Côté É, Durrer C, Gabr RQ, Little JP, Senior P, Steinback C, Davenport MH, Bell GJ, Brocks DR, Boulé NG. Glycemic and Metabolic Effects of Two Long Bouts of Moderate-Intensity Exercise in Men with Normal Glucose Tolerance or Type 2 Diabetes. Front Endocrinol (Lausanne) 2017; 8:154. [PMID: 28744255 PMCID: PMC5504214 DOI: 10.3389/fendo.2017.00154] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 06/20/2017] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND The glycemic and insulinemic responses following 30-60 min of exercise have been extensively studied, and a dose-response has been proposed between exercise duration, or volume, and improvements in glucose tolerance or insulin sensitivity. However, few studies have examined the effects of longer bouts of exercise in type 2 diabetes (T2D). Longer bouts may have a greater potential to affect glucagon, interleukin-6 (IL-6) and incretin hormones [i.e., glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic peptide (GIP)]. AIM To examine the effect of two bouts of long-duration, moderate-intensity exercise on incretins, glucagon, and IL-6 responses before and after exercise, as well as in response to an oral glucose tolerance test (OGTT) conducted the following day. METHODS Twelve men, six with and six without T2D, participated in two separate conditions (i.e., exercise vs. rest) according to a randomized crossover design. On day 1, participants either rested or performed two 90 min bouts of treadmill exercise (separated by 3.5 h) at 80% of their ventilatory threshold. All participants received standardized meals on day 1. On day 2 of each condition, glucose and hormonal responses were measured during a 4-h OGTT. RESULTS On day 1, exercise increased IL-6 at the end of the first bout of exercise (exercise by time interaction p = 0.03) and GIP overall (main effect of exercise p = 0.004). Glucose was reduced to a greater extent in T2D following exercise (exercise by T2D interaction p = 0.03). On day 2, GIP and active GLP-1 were increased in the fasting state (p = 0.05 and p = 0.03, respectively), while plasma insulin and glucagon concentrations were reduced during the OGTT (p = 0.01 and p = 0.02, respectively) in the exercise compared to the rest condition for both healthy controls and T2D. Postprandial glucose was elevated in T2D compared to healthy control (p < 0.05) but was not affected by exercise. CONCLUSION Long-duration, moderate-intensity aerobic exercise can increase IL-6. On the day following exercise, fasting incretins remained increased but postprandial insulin and glucagon were decreased without affecting postprandial glucose. This long duration of exercise may not be appropriate for some people, and further research should investigate why next day glucose tolerance was unchanged.
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Affiliation(s)
- Saeed Reza Eshghi
- Faculty of Physical Education and Recreation, University of Alberta, Edmonton, AB, Canada
- Alberta Diabetes Institute, University of Alberta, Edmonton, AB, Canada
| | - Kevin Fletcher
- Faculty of Physical Education and Recreation, University of Alberta, Edmonton, AB, Canada
- Alberta Diabetes Institute, University of Alberta, Edmonton, AB, Canada
| | - Étienne Myette-Côté
- Faculty of Physical Education and Recreation, University of Alberta, Edmonton, AB, Canada
- Alberta Diabetes Institute, University of Alberta, Edmonton, AB, Canada
| | - Cody Durrer
- School of Health and Exercise Sciences, University of British Columbia, Kelowna, BC, Canada
| | - Raniah Q. Gabr
- National Organization for Drug Control and Research (NODCAR), Giza, Egypt
| | - Jonathan P. Little
- School of Health and Exercise Sciences, University of British Columbia, Kelowna, BC, Canada
| | - Peter Senior
- Alberta Diabetes Institute, University of Alberta, Edmonton, AB, Canada
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Craig Steinback
- Faculty of Physical Education and Recreation, University of Alberta, Edmonton, AB, Canada
- Alberta Diabetes Institute, University of Alberta, Edmonton, AB, Canada
| | - Margie H. Davenport
- Faculty of Physical Education and Recreation, University of Alberta, Edmonton, AB, Canada
- Alberta Diabetes Institute, University of Alberta, Edmonton, AB, Canada
| | - Gordon J. Bell
- Faculty of Physical Education and Recreation, University of Alberta, Edmonton, AB, Canada
- Alberta Diabetes Institute, University of Alberta, Edmonton, AB, Canada
| | - Dion R. Brocks
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB, Canada
| | - Normand G. Boulé
- Faculty of Physical Education and Recreation, University of Alberta, Edmonton, AB, Canada
- Alberta Diabetes Institute, University of Alberta, Edmonton, AB, Canada
- *Correspondence: Normand G. Boulé,
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1366
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Cefalu WT, Boulton AJM, Tamborlane WV, Moses RG, LeRoith D, Greene EL, Hu FB, Bakris G, Wylie-Rosett J, Rosenstock J, Kahn SE, Weinger K, Blonde L, de Groot M, Rich S, D'Alessio D, Reynolds L, Riddle MC. Diabetes Care: "Taking It to the Limit One More Time". Diabetes Care 2017; 40:3-6. [PMID: 27999000 PMCID: PMC5180460 DOI: 10.2337/dc16-2326] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- William T Cefalu
- Pennington Biomedical Research Center, Louisiana State University, Baton Rouge, LA
| | | | | | | | - Derek LeRoith
- Division of Endocrinology, Diabetes and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Eddie L Greene
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - Frank B Hu
- Departments of Nutrition and Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA
| | - George Bakris
- ASH Comprehensive Hypertension Center, Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, The University of Chicago Medicine, Chicago, IL
| | - Judith Wylie-Rosett
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY
| | | | - Steven E Kahn
- Division of Metabolism, Endocrinology and Nutrition, Department of Medicine, VA Puget Sound Health Care System and University of Washington School of Medicine, Seattle, WA
| | - Katie Weinger
- Joslin Diabetes Center, Harvard Medical School, Boston, MA
| | - Lawrence Blonde
- Ochsner Diabetes Clinical Research Unit, Frank Riddick Diabetes Institute, Department of Endocrinology, Ochsner Medical Center, New Orleans, LA
| | - Mary de Groot
- Indiana University School of Medicine, Indianapolis, IN
| | - Stephen Rich
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA
| | - David D'Alessio
- Division of Endocrinology, Diabetes and Metabolism, Duke University, Durham, NC
| | | | - Matthew C Riddle
- Division of Endocrinology, Diabetes and Clinical Nutrition, Oregon Health & Science University, Portland, OR
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1367
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Miller CK, Pawelczyk K, Cheavens JS, Fujita K, Moss S. Development and pilot testing of a novel behavioral intervention for adults with type 2 diabetes using intervention mapping. Health Psychol Behav Med 2017. [DOI: 10.1080/21642850.2017.1377618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Affiliation(s)
- Carla K. Miller
- Department of Human Sciences, Human Nutrition, Ohio State University, Columbus, OH, USA
| | - Katlyn Pawelczyk
- Department of Human Sciences, Human Nutrition, Ohio State University, Columbus, OH, USA
| | | | - Kentaro Fujita
- Department of Psychology, Ohio State University, Columbus, OH, USA
| | - Sara Moss
- Department of Psychology, Ohio State University, Columbus, OH, USA
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1368
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Carson BP. The Potential Role of Contraction-Induced Myokines in the Regulation of Metabolic Function for the Prevention and Treatment of Type 2 Diabetes. Front Endocrinol (Lausanne) 2017; 8:97. [PMID: 28512448 PMCID: PMC5411437 DOI: 10.3389/fendo.2017.00097] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 04/18/2017] [Indexed: 12/19/2022] Open
Abstract
Skeletal muscle represents the largest organ in the body, comprises 36-42% of body weight, and has recently been recognized as having an endocrine function. Proteins expressed and released by muscle that have autocrine, paracrine, and endocrine bioactivities have been termed myokines. It is likely that muscle contraction represents the primary stimulus for the synthesis and secretion of myokines to enable communication with other organs such as the liver, adipose tissue, brain, and auto-regulation of muscle metabolism. To date, several hundred myokines in the muscle secretome have been identified, a sub-population of which are specifically induced by skeletal muscle contraction. However, the bioactivity of many of these myokines and the mechanism through which they act has either not yet been characterized or remains poorly understood. Physical activity and exercise are recognized as a central tenet in both the prevention and treatment of type 2 diabetes (T2D). Recent data suggest humoral factors such as muscle-derived secretory proteins may mediate the beneficial effects of exercise in the treatment of metabolic diseases. This mini-review aims to summarize our current knowledge on the role of contraction-induced myokines in mediating the beneficial effects of physical activity and exercise in the prevention and treatment of T2D, specifically glucose and lipid metabolism. Future directions as to how we can optimize contraction-induced myokine secretion to inform exercise protocols for the prevention and treatment of T2D will also be discussed.
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Affiliation(s)
- Brian P. Carson
- Health Research Institute, Physical Education and Sport Sciences, University of Limerick, Limerick, Ireland
- *Correspondence: Brian P. Carson,
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1369
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A Guide to Physical Activity for Individuals With Diabetes. J Nurse Pract 2017. [DOI: 10.1016/j.nurpra.2016.10.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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1370
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Gomes Bracht C, Sudatti Delevatti R, Fernando Martins Kruel L. Combined Training in the Treatment of Type 2 Diabetes Mellitus: A Review. Health (London) 2017. [DOI: 10.4236/health.2017.912118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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1371
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Young-Hyman D, de Groot M, Hill-Briggs F, Gonzalez JS, Hood K, Peyrot M. Psychosocial Care for People With Diabetes: A Position Statement of the American Diabetes Association. Diabetes Care 2016; 39:2126-2140. [PMID: 27879358 PMCID: PMC5127231 DOI: 10.2337/dc16-2053] [Citation(s) in RCA: 605] [Impact Index Per Article: 75.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Deborah Young-Hyman
- Office of Behavioral and Social Science Research, National Institutes of Health, Bethesda, MD
| | - Mary de Groot
- Indiana University School of Medicine, Indianapolis, IN
| | | | - Jeffrey S Gonzalez
- Yeshiva University and the Albert Einstein College of Medicine, Bronx, NY
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1372
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Mahmoud AA, Peters PA, Civil RH, Remington JS. In vitro killing of schistosomula of Schistosoma mansoni by BCG and C. parvum-activated macrophages. JOURNAL OF IMMUNOLOGY (BALTIMORE, MD. : 1950) 1979; 122:1655-7. [PMID: 376723 PMCID: PMC10512121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 04/07/2023] [Accepted: 04/14/2023] [Indexed: 12/14/2022]
Abstract
Resistance to Schistosoma mansoni infection in the mouse has been induced either specifically by a primary infection with this parasite or nonspecifically by a variety of immunostimulants such as BCG. In the present study we developed an in vitro system to examine the effector mechanism of nonspecifically induced resistance. Activated macrophage monolayers obtained from BCG- or Corynebacterium parvum treated mice killed a respective mean 32 +/- 6% and 48 +/- 5% of schistosomula after 24 hr incubation. The killing of the parasites was verified by their inability to mature to adult worms upon injection into normal mice. The activated macrophage-mediated killing was related to cell:parasite ratio, and was partially lost if the macrophage monolayers were kept in cultures for 24 hr before incubation with the organism. Supernatants of macrophages cultured in the presence of schistosomula killed a mean of 51 +/- 3% of the organisms whereas those from cells cultured alone resulted in a mean killing of 25 +/- 3%. Furthermore, toxic supernatants could be generated equally well on incubation with S. mansoni schistosomula or Trichinella spiralis larvae. Our data show that activated macrophage monolayers through soluble mediators destroy a significant proportion of the multicellular parasite S. mansoni schistosomula in vitro.
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