Anti-Inflammatory and Therapeutic Effects of a Novel Small-Molecule Inhibitor of Inflammation in a Male C57BL/6J Mouse Model of Obesity-Induced NAFLD/MAFLD

Purpose

Non-alcoholic fatty liver disease (NAFLD), recently renamed metabolic (dysfunction) associated fatty liver disease (MAFLD), is the most common chronic liver disease in the United States. Presently, there is an intense and ongoing effort to identify and develop novel therapeutics for this disease. In this study, we explored the anti-inflammatory activity of a new compound, termed IOI-214, and its therapeutic potential to ameliorate NAFLD/MAFLD in male C57BL/6J mice fed a high fat (HF) diet.

Methods

Murine macrophages and hepatocytes in culture were treated with lipopolysaccharide (LPS) ± IOI-214 or DMSO (vehicle), and RT-qPCR analyses of inflammatory cytokine gene expression were used to assess IOI-214's anti-inflammatory properties in vitro. Male C57BL/6J mice were also placed on a HF diet and treated once daily with IOI-214 or DMSO for 16 weeks. Tissues were collected and analyzed to determine the effects of IOI-214 on HF diet-induced NAFL D/MAFLD. Measurements such as weight, blood glucose, serum cholesterol, liver/serum triglyceride, insulin, and glucose tolerance tests, ELISAs, metabolomics, Western blots, histology, gut microbiome, and serum LPS binding protein analyses were conducted.

Results

IOI-214 inhibited LPS-induced inflammation in macrophages and hepatocytes in culture and abrogated HF diet-induced mesenteric fat accumulation, hepatic inflammation and steatosis/hepatocellular ballooning, as well as fasting hyperglycemia without affecting insulin resistance or fasting insulin, cholesterol or TG levels despite overall obesity in vivo in male C57BL/6J mice. IOI-214 also decreased systemic inflammation in vivo and improved gut microbiota dysbiosis and leaky gut.

Conclusion

Combined, these data indicate that IOI-214 works at multiple levels in parallel to inhibit the inflammation that drives HF diet-induced NAFLD/MAFLD, suggesting that it may have therapeutic potential for NAFLD/MAFLD.

Toll-Like Receptor 3 Is Critical to the Pancreatic Islet Milieu That Is Required for Coxsackievirus B4-Induced Type 1 Diabetes in Female Nonobese Diabetic Mice

OBJECTIVE

Genetic and environmental influences play a role as triggers of type 1 diabetes mellitus (T1DM). Female nonobese diabetic (NOD) mice are useful for studying T1DM as they spontaneously develop T1DM, which can be accelerated by some viruses. Toll-like receptor 3 (TLR3) is believed to play a critical role in viral-induced T1DM and β-cell destruction, because female Tlr3 knockout (Tlr3-/-) NOD mice are protected from Coxsackievirus B4 (CVB4)-induced acceleration of T1DM. However, the exact role(s) TLR3 plays in the pathogenesis of CVB4-induced T1DM remain unknown.

METHODS

This longitudinal study used immunostaining, laser capture microdissection, and reverse transcription real-time polymerase chain reaction of islets from female uninfected and CVB4-infected Tlr3+/+ and Tlr3-/- NOD mice.

RESULTS

Islets isolated from female Tlr3+/+ NOD mice 4 to 8 weeks of age had higher amounts of insulitis, Cxcl10, Il1b, Tnfa, and Tgfb1 expression compared with Tlr3-/- NOD mice. After CVB4 infection, Tlr3+/+ NOD mice had higher amounts of insulitis and T-cell infiltration at 3 days after infection compared with Tlr3-/- CVB4-infected NOD mice.

CONCLUSIONS

Toll-like receptor 3 is necessary for establishment of a pancreatic islet inflammatory microenvironment by increasing insulitis and cytokine expression that facilitates CVB4-induced T1DM in female NOD mice.

Primary Care Diabetes Fellowship Programs: Developing National Standards

The rapid and constant increase in the number of people living with diabetes has outstripped the capacity of specialists to fully address this chronic disease alone. Furthermore, although most people with diabetes are treated in the primary care setting, most primary care providers feel under-prepared and under-resourced to fully address the needs of their patients with diabetes. Addressing this care gap will require a multifaceted approach centering on primary care training in diabetes and its complications. One-year diabetology fellowship programs are well situated to provide this training. Previous research has shown that the higher the diabetes-specific volume of patients seeing a primary care physician was, the better the quality outcomes were across six quality indicators (eye examinations, LDL cholesterol testing, A1C testing, prescriptions for ACE inhibitors or angiotensin receptor blockers, prescriptions for statins, and emergency department visits for hypoglycemia or hyperglycemia). Primary care diabetes fellowships have existed for many years, but the number of fellowships and fellowship positions has recently grown dramatically. This article proposes a standardized curriculum for such programs and makes the case for increasing their number in the United States.

Coxsackievirus B4 Exposure Results in Variable Pattern Recognition Response in the Kidneys of Female Non-Obese Diabetic Mice Before Establishment of Diabetes

End-stage renal disease (ESRD) is described by four primary diagnoses, diabetes, hypertension, glomerulonephritis, and cystic kidney disease, all of which have viruses implicated as causative agents. Enteroviruses, such as coxsackievirus (CV), are a common genus of viruses that have been implicated in both diabetes and cystic kidney disease; however, little is known about how CVs cause kidney injury and ESRD or predispose individuals with a genetic susceptibility to type 1 diabetes (T1D) to kidney injury. This study evaluated kidney injury resulting from coxsackievirus B4 (CVB4) inoculation of non-obese diabetic (NOD) mice to glean a better understanding of how viral exposure may predispose individuals with a genetic susceptibility to T1D to kidney injury. The objectives were to assess acute and chronic kidney damage in CVB4-inoculated NOD mice without diabetes. Results indicated the presence of CVB4 RNA in the kidney for at least 14 days post-CVB4 inoculation and a coordinated pattern recognition receptor response, but the absence of an immune response or cytotoxicity. CVB4-inoculated NOD mice also had a higher propensity to develop an increase in mesangial area 17 weeks post-CVB4 inoculation. These studies identified initial gene expression changes in the kidney resulting from CVB4 exposure that may predispose to ESRD. Thus, this study provides an initial characterization of kidney injury resulting from CVB4 inoculation of mice that are genetically susceptible to developing T1D that may one day provide better therapeutic options and predictive measures for patients who are at risk for developing kidney disease from T1D.

Identification of a novel selective and potent inhibitor of glycogen synthase kinase-3

Glycogen synthase kinase-3 (GSK-3) is a multitasking protein kinase that regulates numerous critical cellular functions. Not surprisingly, elevated GSK-3 activity has been implicated in a host of diseases including pathological inflammation, diabetes, cancer, arthritis, asthma, bipolar disorder, and Alzheimer's. Therefore, reagents that inhibit GSK-3 activity provide a means to investigate the role of GSK-3 in cellular physiology and pathophysiology and could become valuable therapeutics. Finding a potent inhibitor of GSK-3 that can selectively target this kinase, among over 500 protein kinases in the human genome, is a significant challenge. Thus there remains a critical need for the identification of selective inhibitors of GSK-3. In this work, we introduce a novel small organic compound, namely COB-187, which exhibits potent and highly selective inhibition of GSK-3. Specifically, this study 1) utilized a molecular screen of 414 kinase assays, representing 404 unique kinases, to reveal that COB-187 is a highly potent and selective inhibitor of GSK-3; 2) utilized a cellular assay to reveal that COB-187 decreases the phosphorylation of canonical GSK-3 substrates indicating that COB-187 inhibits cellular GSK-3 activity; and 3) reveals that a close isomer of COB-187 is also a selective and potent inhibitor of GSK-3. Taken together, these results demonstrate that we have discovered a region of chemical design space that contains novel GSK-3 inhibitors. These inhibitors will help to elucidate the intricate function of GSK-3 and can serve as a starting point for the development of potential therapeutics for diseases that involve aberrant GSK-3 activity.

Time Needed for Diabetes Self-Care: Nationwide Survey of Certified Diabetes Educators

PURPOSE

To approximate the time required for self-care of individuals with diabetes, as estimated by certified diabetes educators (CDEs).

METHODS

A survey was sent to the CDE member list of the American Association of Diabetes Educators (AADE). The survey asked the CDEs to estimate the time in minutes/day needed for 1) each component of diabetes self-care and 2) all components of diabetes management as recommended by the American Diabetes Association and AADE. Estimates were for two sample patients: 1) an adult with type 2 diabetes (for at least 1 year) on oral medications who performs self-monitoring of blood glucose (SMBG) twice daily and 2) a school-age child with established type 1 diabetes (for at least 1 year) who takes four insulin injections per day and has SMBG four times daily.

RESULTS

A total of 674 CDEs completed and returned the survey. The mean times needed for an adult with type 2 diabetes for routine, daily diabetes self-management and for all recommended components of self-care were estimated to be 66 and 234 minutes, respectively. The mean times needed for a child with type 1 diabetes for routine, daily diabetes self-management and for all recommended components of self-care were estimated to be 78 and 305 minutes, respectively.

CONCLUSION

The total estimated time needed daily for recommended diabetes self-care was ~4 hours for adults and >5 hours for children-far more than is reasonably feasible for most people with diabetes. This information should be considered when helping patients with diabetes achieve self-care goals.

Diabetes Fellowship in Primary Care: A Survey of Graduates

Context

The diabetes pandemic has outpaced the US supply of diabetes specialists and has overwhelmed primary care providers (physicians, physician assistants, and nurse practitioners). Primary care diabetes fellowships can be used to address this workforce shortage.

Objectives

To determine the skills obtained during 2 diabetes fellowship programs, the barriers encountered in practice, the impact of the programs on career paths, and perceived acceptance by patients and colleagues.

Methods

A Qualtrics link to a 26-item survey was sent via email to all graduates of the Ohio University Heritage College of Osteopathic Medicine and East Carolina University Brody School of Medicine diabetes fellowship programs. Items included demographic information, comfort level with different clinical diabetes skills, and current system barriers encountered in their practices.

Results

Of 39 graduates, 36 completed the survey. The most beneficial skills acquired during the fellowship were insulin pump management (13 [36%]), insulin management (10 [29%]), and diabetes pharmacology (6 [17%]). The most common barrier was the lack of board certification as a diabetologist, which affected time with patients and insurance reimbursement. The perceived acceptance by patients was high (25 [69%]), and the perceived receptiveness by colleagues was mostly neutral (7 [19%]) or positive (10 [29%]). The most common postfellowship career path was primary care medicine (15) followed by hospitalist (7) and diabetologist (5).

Conclusion

Physicians who completed the diabetes fellowship training reported high comfort levels with treating patients with diabetes, but they also reported the barriers faced in an unrecognized specialty.

The Promise and Perils of Wearable Physiological Sensors for Diabetes Management

Development of truly useful wearable physiologic monitoring devices for use in diabetes management is still in its infancy. From wearable activity monitors such as fitness trackers and smart watches to contact lenses measuring glucose levels in tears, we are just at the threshold of their coming use in medicine. Ultimately, such devices could help to improve the performance of sense-and-respond insulin pumps, illuminate the impact of physical activity on blood glucose levels, and improve patient safety. This is a summary of our experience attempting to use such devices to enhance continuous glucose monitoring-augmented insulin pump therapy. We discuss the current status and present difficulties with available devices, and review the potential for future use.

Endocrinologists' Opinions of Diabetology as a Primary Care Subspecialty

IN BRIEF This study was conducted to ascertain the opinions of endocrinologists about diabetes care as it relates to the health care provider workforce. A survey was administered to endocrinologists in the Planning Research in Inpatient Diabetes and Planning Research in Outpatient Diabetes (PRIDE/PROUD) group and given to attendees of the American Diabetes Association (ADA) Scientific Sessions special interest group whose focus was primary care. The majority of respondents agreed that there is a need for more providers to be trained to take care of patients with diabetes and that more trained providers are needed, and almost half agreed that primary care providers (PCPs) with advanced training in diabetes should be part of the workforce for managing the diabetes pandemic. Expanding diabetes fellowship programs for PCPs remains an important potential solution for addressing workforce development needs in diabetes care.

Phenylmethimazole and a thiazole derivative of phenylmethimazole inhibit IL-6 expression by triple negative breast cancer cells

Inhibition of interleukin-6 (IL-6) holds significant promise as a therapeutic approach for triple negative breast cancer (TNBC). We previously reported that phenylmethimazole (C10) reduces IL-6 expression in several cancer cell lines. We have identified a more potent derivative of C10 termed COB-141. In the present work, we tested the hypothesis that C10 and COB-141 inhibit TNBC cell expressed IL-6 and investigated the potential for classical IL-6 pathway induced signaling within TNBC cells. A panel of TNBC cell lines (MDA-MB-231, Hs578T, MDA-MB-468) was used. Enzyme linked immunosorbent assays (ELISA) revealed that C10 and COB-141 inhibit MDA-MB-231 cell IL-6 secretion, with COB-141 being ~6.5 times more potent than C10. Therefore, the remainder of the study focused on COB-141 which inhibited IL-6 secretion, and was found, via quantitative real time polymerase chain reaction (QRT-PCR), to inhibit IL-6 mRNA in the TNBC panel. COB-141 had little, if any, effect on metabolic activity indicating that the IL-6 inhibition is not via a toxic effect. Flow cytometric analysis and QRT-PCR revealed that the TNBC cell lines do not express the IL-6 receptor (IL-6Rα). Trans-AM assays suggested that COB-141 exerts its inhibitory effect, at least in part, by reducing NF-κB (p65/p50) DNA binding. In summary, COB-141 is a potent inhibitor of TNBC cell expressed IL-6 and the inhibition does not appear to be due to non-specific toxicity. The TNBC cell lines do not have an intact classical IL-6 signaling pathway. COB-141's inhibitory effect may be due, at least in part, to reducing NF-κB (p65/p50) DNA binding.

Fine Needle Aspiration of Thyroid Nodules Using the Bethesda System for Reporting Thyroid Cytopathology: An Institutional Experience in a Rural Setting

Background. Fine needle aspiration (FNA) remains the first-line diagnostic in management of thyroid nodules and reduces unnecessary surgeries. However, it is still challenging since cytological results are not always straightforward. This study aimed to examine the results of thyroid FNA using the Bethesda system for reporting thyroid cytopathology (TBSRTC) to establish the level of accuracy of FNA procedures in a rural practice setting. Method. A retrospective chart review was conducted on existing thyroid FNA performed in a referral endocrine center between December 2011 and November 2015. Results. A total of 159 patients (18-88 years old) and 236 nodule aspirations were performed and submitted for evaluation. 79% were benign, 3% atypia/follicular lesion of unknown significance (AUS/FLUS), 5% follicular neoplasm/suspicious for follicular neoplasm (FN/SFN), 4% suspicious for malignancy (one case was indeed an atypical parathyroid neoplasm by surgical pathology), 2% malignant, and 7% nondiagnostic. Two cases also had advanced molecular analysis on FNA specimens before thyroidectomy. Conclusion. The diagnostic yield of FNA cytology from our practice in a rural setting suggests that accuracy and specificity are comparable to results from larger centers.

Hypoglycemia in Type 2 Diabetes--More Common Than You Think: A Continuous Glucose Monitoring Study

BACKGROUND

Hypoglycemia is often the limiting factor for intensive glucose control in diabetes management, however its actual prevalence in type 2 diabetes (T2DM) is not well documented.

METHODOLOGY

A total of 108 patients with T2DM wore a continuous glucose monitoring system (CGMS) for 5 days. Rates and patterns of hypoglycemia and glycemic variability (GV) were calculated. Patient and medication factors were correlated with rates, timing, and severity of hypoglycemia.

RESULTS

Of the patients, 49.1% had at least 1 hypoglycemic episode (mean 1.74 episodes/patient/ 5 days of CGMS) and 75% of those patients experienced at least 1 asymptomatic hypoglycemic episode. There was no significant difference in the frequency of daytime versus nocturnal hypoglycemia. Hypoglycemia was more frequent in individuals on insulin (alone or in combination) (P = .02) and those on oral hypoglycemic agents (P < .001) compared to noninsulin secretagogues. CGMS analysis resulted in treatment modifications in 64% of the patients. T2DM patients on insulin exhibited higher glycemic variability (GV) scores (2.3 ± 0.6) as compared to those on oral medications (1.8 ± 0.7, P = .017).

CONCLUSIONS

CGMS can provide rich data that show glucose excursions in diabetes patients throughout the day. Consequently, unwarranted onset of hypo- and hyperglycemic events can be detected, intervened, and prevented by using CGMS. Hypoglycemia was frequently unrecognized by the patients in this study (75%), which increases their potential risk of significant adverse events. Incorporation of CGMS into the routine management of T2DM would increase the detection and self-awareness of hypoglycemia resulting in safer and potentially better overall control.

Simple modifications to methimazole that enhance its inhibitory effect on tumor necrosis factor-α-induced vascular cell adhesion molecule-1 expression by human endothelial cells

The expression of vascular cell adhesion molecule-1 (VCAM-1) on the vascular endothelium can be increased by pro-inflammatory cytokines [e.g. tumor necrosis factor-α (TNF-α)]. VCAM-1 contributes to leukocyte adhesion to, and emigration from, the vasculature which is a key aspect of pathological inflammation. As such, a promising therapeutic approach for pathological inflammation is to inhibit the expression of VCAM-1. Methimazole [3-methyl-1, 3 imidazole-2 thione (MMI)] is routinely used for the treatment of Graves׳ disease and patients treated with MMI have decreased levels of circulating VCAM-1. In this study we used cultured human umbilical vein endothelial cells (HUVEC) to investigate the effect of MMI structural modifications on TNF-α induced VCAM-1 expression. We found that addition of a phenyl ring at the 4-nitrogen of MMI yields a compound that is significantly more potent than MMI at inhibiting 24h TNF-α-induced VCAM-1 protein expression. Addition of a para methoxy to the appended phenyl group increases the inhibition while substitution of a thiazole ring for an imidazole ring in the phenyl derivatives yields no clear difference in inhibition. Addition of the phenyl ring to MMI appears to increase toxicity as does substitution of a thiazole ring for an imidazole ring in the phenyl MMI derivatives. Each of the compounds reduced TNF-α-induced VCAM-1 mRNA expression and had a functional inhibitory effect, i.e. each inhibited monocytic cell adhesion to 24h TNF-α-activated HUVEC under fluid flow conditions. Combined, these studies provide important insights into the design of MMI-related anti-inflammatory compounds.

Toll-like receptor 3 is critical for coxsackievirus B4-induced type 1 diabetes in female NOD mice

Group B coxsackieviruses (CVBs) are involved in triggering some cases of type 1 diabetes mellitus (T1DM). However, the molecular mechanism(s) responsible for this remain elusive. Toll-like receptor 3 (TLR3), a receptor that recognizes viral double-stranded RNA, is hypothesized to play a role in virus-induced T1DM, although this hypothesis is yet to be substantiated. The objective of this study was to directly investigate the role of TLR3 in CVB-triggered T1DM in nonobese diabetic (NOD) mice, a mouse model of human T1DM that is widely used to study both spontaneous autoimmune and viral-induced T1DM. As such, we infected female wild-type (TLR3(+/+)) and TLR3 knockout (TLR3(-/-)) NOD mice with CVB4 and compared the incidence of diabetes in CVB4-infected mice with that of uninfected counterparts. We also evaluated the islets of uninfected and CVB4-infected wild-type and TLR3 knockout NOD mice by immunohistochemistry and insulitis scoring. TLR3 knockout mice were markedly protected from CVB4-induced diabetes compared with CVB4-infected wild-type mice. CVB4-induced T-lymphocyte-mediated insulitis was also significantly less severe in TLR3 knockout mice compared with wild-type mice. No differences in insulitis were observed between uninfected animals, either wild-type or TLR3 knockout mice. These data demonstrate for the first time that TLR3 is 1) critical for CVB4-induced T1DM, and 2) modulates CVB4-induced insulitis in genetically prone NOD mice.

Diet is critical for prolonged glycemic control after short-term insulin treatment in high-fat diet-induced type 2 diabetic male mice

Background

Clinical studies suggest that short-term insulin treatment in new-onset type 2 diabetes (T2DM) can promote prolonged glycemic control. The purpose of this study was to establish an animal model to examine such a “legacy” effect of early insulin therapy (EIT) in long-term glycemic control in new-onset T2DM. The objective of the study was to investigate the role of diet following onset of diabetes in the favorable outcomes of EIT.

Methodology

As such, C57BL6/J male mice were fed a high-fat diet (HFD) for 21 weeks to induce diabetes and then received 4 weeks of daily insulin glargine or sham subcutaneous injections. Subsequently, mice were either kept on the HFD or switched to a low-fat diet (LFD) for 4 additional weeks.

Principal Findings

Mice fed a HFD gained significant fat mass and displayed increased leptin levels, increasing insulin resistance (poor HOMA-IR) and worse glucose tolerance test (GTT) performance in comparison to mice fed a LFD, as expected. Insulin-treated diabetic mice but maintained on the HFD demonstrated even greater weight gain and insulin resistance compared to sham-treated mice. However, insulin-treated mice switched to the LFD exhibited a better HOMA-IR compared to those mice left on a HFD. Further, between the insulin-treated and sham control mice, in spite of similar HOMA-IR values, the insulin-treated mice switched to a LFD following insulin therapy did demonstrate significantly better HOMA-B% values than sham control and insulin-treated HFD mice.

Conclusion/Interpretation

Early insulin treatment in HFD-induced T2DM in C57BL6/J mice was only beneficial in animals that were switched to a LFD after insulin treatment which may explain why a similar legacy effect in humans is achieved clinically in only a portion of cases studied, emphasizing a vital role for diet adherence in diabetes control.

Glycemic Variability in Type 1 Diabetes—Does It Matter?

Clinical assessment of glycemic variability (GV) attempts to measure factors that may be contribute to tissue damage and the complications of diabetes that are not measured in glycosylated hemoglobin (HbA1C). Physicians managing patients with diabetes immediately understand the concept of GV; however, how it is assessed in clinical research trials and whether it has any predictive power in patients with type 1 diabetes is controversial and uncertain. This review is intended to help the reader understand the various GV metrics currently being reported in the literature, the potential mechanisms by which GV may contribute to the pathogenesis of the long-term complications of diabetes, and, finally, the evidence that reducing GV is beneficial to patients with type 1 diabetes.

Use of Automated Bolus Calculators for Diabetes Management

Fewer than 30 % of patients with diabetes who are on insulin therapy achieve target glycated haemoglobin (HbA1C) levels. Automated bolus calculators (ABCs) are now almost universally used for patients on insulin pump therapy to calculate pre-meal insulin doses. Use of ABCs in glucose monitors and smart phone applications have the potential to improve glucose control in a larger population of individuals with diabetes on insulin therapy by overcoming the fear of hypoglycaemia and assisting those with low numeracy skills.

A consensus perceived glycemic variability metric

OBJECTIVE

Glycemic variability (GV) is an important component of overall glycemic control for patients with diabetes mellitus. Physicians are able to recognize excessive GV from continuous glucose monitoring (CGM) plots; however, there is currently no universally agreed upon GV metric. The objective of this study was to develop a consensus perceived glycemic variability (CPGV) metric that could be routinely applied to CGM data to assess diabetes mellitus control.

METHODS

Twelve physicians actively managing patients with type 1 diabetes mellitus rated a total of 250 24 h CGM plots as exhibiting low, borderline, high, or extremely high GV. Ratings were averaged to obtain a consensus and then input into two machine learning algorithms: multilayer perceptrons (MPs) and support vector machines for regression (SVR). In silica experiments were run using each algorithm with different combinations of 12 descriptive input features. Ten-fold cross validation was used to evaluate the performance of each model.

RESULTS

The SVR models approximated the physician consensus ratings of unseen CGM plots better than the MP models. When judged by the root mean square error, the best SVR model performed comparably to individual physicians at matching consensus ratings. When applied to 262 different CGM plots as a screen for excessive GV, this model had accuracy, sensitivity, and specificity of 90.1%, 97.0%, and 74.1%, respectively. It significantly outperformed mean amplitude of glycemic excursion, standard deviation, distance traveled, and excursion frequency.

CONCLUSIONS

This new CPGV metric could be used as a routine measure of overall glucose control to supplement glycosylated hemoglobin in clinical practice.

Phenylmethimazole suppresses dsRNA-induced cytotoxicity and inflammatory cytokines in murine pancreatic beta cells and blocks viral acceleration of type 1 diabetes in NOD mice

Accumulating evidence supports a role for viruses in the pathogenesis of type 1 diabetes mellitus (T1DM). Activation of dsRNA-sensing pathways by viral dsRNA induces the production of inflammatory cytokines and chemokines that trigger beta cell apoptosis, insulitis, and autoimmune-mediated beta cell destruction. This study was designed to evaluate and describe potential protective effects of phenylmethimazole (C10), a small molecule which blocks dsRNA-mediated signaling, on preventing dsRNA activation of beta cell apoptosis and the inflammatory pathways important in the pathogenesis of T1DM. We first investigated the biological effects of C10, on dsRNA-treated pancreatic beta cells in culture. Cell viability assays, quantitative real-time PCR, and ELISAs were utilized to evaluate the effects of C10 on dsRNA-induced beta cell cytotoxicity and cytokine/chemokine production in murine pancreatic beta cells in culture. We found that C10 significantly impairs dsRNA-induced beta cell cytotoxicity and up-regulation of cytokines and chemokines involved in the pathogenesis of T1DM, which prompted us to evaluate C10 effects on viral acceleration of T1DM in NOD mice. C10 significantly inhibited viral acceleration of T1DM in NOD mice. These findings demonstrate that C10 (1) possesses novel beta cell protective activity which may have potential clinical relevance in T1DM and (2) may be a useful tool in achieving a better understanding of the role that dsRNA-mediated responses play in the pathogenesis of T1DM.

Automated glycemic pattern analysis: overcoming diabetes clinical inertia

The OneTouch® Verio™ IQ Meter with PatternAlert™ Technology has been approved by the U.S. Food and Drug Administration as the first self-glucose monitor that can automatically determine glycemic patterns [high and low pre-meal blood glucose (BG)] for health care providers (HCPs) and patients. In this issue of Journal of Diabetes Science and Technology, Katz and coauthors demonstrate that this device was more accurate and quicker in detecting abnormal glucose patterns than the review by HCPs of 30-day handwritten BG logs and that its interpretations were positively accepted by the HCPs. Continued development of automated pattern analysis and decision-support software to overcome the "data-overload" associated with intensive glucose monitoring and diabetes management will reduce clinical inertia and could dramatically improve diabetes outcomes.

How well are we managing diabetes in long-term care?

The care received by nursing home residents with diabetes does not meet ADA standards for ambulatory adults, this study finds. Nor should it. The frail elderly need new standards that address their particular needs.

Coexistence of Cushing syndrome from functional adrenal adenoma and Addison disease from immune-mediated adrenalitis

A 56-year-old woman presented with an incidental adrenal adenoma and physical examination findings that included moderate obesity, a slight cervicothoracic fat pad ("buffalo hump"), increased supraclavicular fat pads, and white abdominal striae. Biochemical workup revealed elevated levels of 24-hour urinary free cortisol but normal serum morning cortisol and suppressed levels of corticotropin, suggestive of adrenal-dependent Cushing syndrome. The resected adrenal gland revealed macronodular cortical hyperplasia with a dominant nodule. Other findings included an absent cortisol response to corticotropin stimulation, presence of serum anti-21-hydroxylase antibodies, and mononuclear cell infiltration--consistent with adrenalitis. The findings represent, to the authors' knowledge, the first known case of a patient with coexistent functional cortisol-secreting macronodular adrenal tumor resulting in Cushing syndrome and immune-mediated adrenalitis resulting in Addison disease.

Analysis of use of an automated bolus calculator reduces fear of hypoglycemia and improves confidence in dosage accuracy in type 1 diabetes mellitus patients treated with multiple daily insulin injections

In this issue of Journal of Diabetes Science and Technology, Barnard and colleagues evaluate the use of the ACCU-CHEK® Aviva Expert blood glucose meter/bolus advisor system in patients with type 1 diabetes mellitus. Hypoglycemia is a major limiting factor to intensive glucose control, and fear of hypoglycemia, especially in those who have experienced severe reactions, is a major barrier. The bolus advisor improved overall glucose control and increased adherence by overcoming the patients' fear of hypoglycemia, giving them more confidence to give adequate doses of insulin to control hyperglycemia. In this review, we discuss other human factors that become barriers to intensive control, which can benefit from new technologies, including numeracy literacy, information overload, time required for diabetes self-care, and device incompatibility.

Characterizing blood glucose variability using new metrics with continuous glucose monitoring data

OBJECTIVE

Glycemic variability contributes to oxidative stress, which has been linked to the pathogenesis of the long-term complications of diabetes. Currently, the best metric for assessing glycemic variability is mean amplitude of glycemic excursion (MAGE); however, MAGE is not in routine clinical use. A glycemic variability metric in routine clinical use could potentially be an important measure of overall glucose control and a predictor of diabetes complication risk not detected by glycosylated hemoglobin (A1C) levels. This study aimed to develop and evaluate new automated metrics of glycemic variability that could be routinely applied to continuous glucose monitoring (CGM) data to assess and enhance glucose control.

METHOD

Individual 24 h CGM tracings from our clinical diabetes research database were scored for MAGE and two additional metrics designed to compensate for aspects of variability not captured by MAGE: (1) number of daily glucose fluctuations >75 mg/dl that leave the normal range (70-175 mg/dl), or excursion frequency, and (2) total daily fluctuation, or distance traveled. These scores were used to train machine learning algorithms to recognize excessive variability based on physician ratings of daily CGM charts, producing a third metric of glycemic variability: perceived variability. Finger stick A1C (average) and serum 1,5-anhydroglucitol (postprandial) levels were used as clinical markers of overall glucose control for comparison.

RESULTS

Mean amplitude of glycemic excursion, excursion frequency, and distance traveled did not adequately quantify the glycemic variability visualized by physicians who evaluated the daily CGM plots. A naive Bayes classifier was developed that characterizes CGM tracings based on physician interpretations of tracings. Preliminary results suggest that the number of excessively variable days, as determined by this naive Bayes classifier, may be an effective way to automatically assess glycemic variability of CGM data. This metric more closely reflects 90-day changes in serum 1,5-anhydroglucitol levels than does MAGE.

CONCLUSION

We have developed a new automated metric to assess overall glycemic variability in people with diabetes using CGM, which could easily be incorporated into commercially available CGM software. Additional work to validate and refine this metric is underway. Future studies are planned to correlate the metric with both urinary 8-iso-prostaglandin F2 alpha excretion and serum 1,5-anhydroglucitol levels to see how well it identifies patients with high glycemic variability and increased markers of oxidative stress to assess risk for long-term complications of diabetes.

Phenylmethimazole blocks palmitate-mediated induction of inflammatory cytokine pathways in 3T3L1 adipocytes and RAW 264.7 macrophages

Visceral adipocytes and associated macrophages produce and release excessive amounts of biologically active inflammatory cytokines via the portal and systemic vascular system, which induce insulin resistance in insulin target tissues such as fat, liver, and muscle. Free fatty acids (FFAs) absorbed via the portal system or released from adipocytes also induce insulin resistance. In this report, we show that phenylmethimazole (C10) blocks basal IL6 and leptin production as well as basal Socs-3 expression in fully differentiated 3T3L1 cells (3T3L1 adipocytes) without affecting insulin-stimulated AKT signaling. In addition, C10 inhibits palmitate-induced IL6 and iNos up-regulation in both 3T3L1 adipocytes and RAW 264.7 macrophages, LPS-induced NF-κB and IFN-β activation in 3T3L1 cells, and LPS-induced iNos, Ifn-β, Il1β, Cxcl10, and Il6 expression in RAW 264.7 macrophages. C10 also blocks palmitate-induced Socs-3 up-regulation and insulin receptor substrate-1 (IRS-1) serine 307 phosphorylation in 3T3L1 adipocytes. Additionally, we show for the first time that although palmitate increases IRS-1 serine 307 phosphorylation in 3T3L1 adipocytes, AKT serine 473 phosphorylation is enhanced, not reduced, by palmitate. These results suggest that through inhibition of FFA-mediated signaling in adipocytes and associated macrophages, as well as possibly other insulin target cells/tissues (i.e. non-immune cells), C10 might be efficacious to prevent or reverse cytokine-induced insulin resistance seen in obesity-related insulin resistance and type 2 diabetes mellitus.

Evaluating the automated blood glucose pattern detection and case-retrieval modules of the 4 Diabetes Support System

BACKGROUND

We have developed a prototypical case-based reasoning system to enhance management of patients with type 1 diabetes mellitus (T1DM). The system is capable of automatically analyzing large volumes of life events, self-monitoring of blood glucose readings, continuous glucose monitoring system results, and insulin pump data to detect clinical problems. In a preliminary study, manual entry of large volumes of life-event and other data was too burdensome for patients. In this study, life-event and pump data collection were automated, and then the system was reevaluated.

METHODS

Twenty-three adult T1DM patients on insulin pumps completed the five-week study. A usual daily schedule was entered into the database, and patients were only required to upload their insulin pump data to Medtronic's CareLink® Web site weekly. Situation assessment routines were run weekly for each participant to detect possible problems, and once the trial was completed, the case-retrieval module was tested.

RESULTS

Using the situation assessment routines previously developed, the system found 295 possible problems. The enhanced system detected only 2.6 problems per patient per week compared to 4.9 problems per patient per week in the preliminary study (p=.017). Problems detected by the system were correctly identified in 97.9% of the cases, and 96.1% of these were clinically useful.

CONCLUSIONS

With less life-event data, the system is unable to detect certain clinical problems and detects fewer problems overall. Additional work is needed to provide device/software interfaces that allow patients to provide this data quickly and conveniently.

Exploration of the DPP-4 inhibitors with a focus on saxagliptin

BACKGROUND

Type 2 diabetes (T2DM) has become a worldwide epidemic. Despite a vast array of new compounds to treat T2DM, recommended treatment goals are consistently not achieved in this country thus suggesting a need to increase treatment options.

OBJECTIVE

To review the role of DPP-4 inhibitors in treatment of T2DM with an emphasis on saxagliptin.

METHODS

The authors discuss the role of this new class of medications in treatment of T2DM, review the current available studies and the unique characteristics of saxagliptin.

RESULTS AND CONCLUSIONS

Saxagliptin, a DPP-4 inhibitor, is one of an important new class of compounds, which seems to be particularly safe and effective especially in early treatment of T2DM.

Phenylmethimazole decreases Toll-like receptor 3 and noncanonical Wnt5a expression in pancreatic cancer and melanoma together with tumor cell growth and migration

PURPOSE

To evaluate whether (a) Wnt5a expression in pancreatic cancer and malignant melanoma cells might be associated with constitutive levels of Toll-like receptor 3 (TLR3) and/or TLR3 signaling; (b) phenylmethimazole (C10), a novel TLR signaling inhibitor, could decrease constitutive Wnt5a and TLR3 levels together with cell growth and migration; and (c) the efficacy of C10 as a potential inhibitor of pancreatic cancer and malignant melanoma cell growth in vivo.

EXPERIMENTAL DESIGN

We used a variety of molecular biology techniques including but not limited to PCR, Western blotting, and ELISA to evaluate the presence of constitutively activated TLR3/Wnt5a expression and signaling. 3-(4,5-Dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide-based technology and scratch assays were used to evaluate inhibition of cell growth and migration, respectively. TLR3 regulation of cell growth was confirmed using small interfering RNA technology. Nude and severe combined immunodeficient mice were implanted with human pancreatic cancer and/or melanoma cells and the effects of C10 on tumor growth were evaluated.

RESULTS

We show that constitutive TLR3 expression is associated with constitutive Wnt5a in human pancreatic cancer and malignant melanoma cell lines, that C10 can decrease constitutive TLR3/Wnt5a expression and signaling, suggesting that they are interrelated signal systems, and that C10 inhibits growth and migration in both of these cancer cell lines. We also report that C10 is effective at inhibiting human pancreatic cancer and malignant melanoma tumor growth in vivo in nude or severe combined immunodeficient mice and associate this with inhibition of signal transducers and activators of transcription 3 activation.

CONCLUSIONS

C10 may have potential therapeutic applicability in pancreatic cancer and malignant melanoma.

Use of case-based reasoning to enhance intensive management of patients on insulin pump therapy

BACKGROUND

This study was conducted to develop case-based decision support software to improve glucose control in patients with type 1 diabetes mellitus (T1DM) on insulin pump therapy. While the benefits of good glucose control are well known, achieving and maintaining good glucose control remains a difficult task. Case-based decision support software may assist by recalling past problems in glucose control and their associated therapeutic adjustments.

METHODS

Twenty patients with T1DM on insulin pumps were enrolled in a 6-week study. Subjects performed self-glucose monitoring and provided daily logs via the Internet, tracking insulin dosages, work, sleep, exercise, meals, stress, illness, menstrual cycles, infusion set changes, pump problems, hypoglycemic episodes, and other events. Subjects wore a continuous glucose monitoring system at weeks 1, 3, and 6. Clinical data were interpreted by physicians, who explained the relationship between life events and observed glucose patterns as well as treatment rationales to knowledge engineers. Knowledge engineers built a prototypical system that contained cases of problems in glucose control together with their associated solutions.

RESULTS

Twelve patients completed the study. Fifty cases of clinical problems and solutions were developed and stored in a case base. The prototypical system detected 12 distinct types of clinical problems. It displayed the stored problems that are most similar to the problems detected, and offered learned solutions as decision support to the physician.

CONCLUSIONS

This software can screen large volumes of clinical data and glucose levels from patients with T1DM, identify clinical problems, and offer solutions. It has potential application in managing all forms of diabetes.

Novel CDH3 mutations in hypotrichosis with juvenile macular dystrophy

BACKGROUND

Hypotrichosis with juvenile macular dystrophy (HJMD) is a rare autosomal recessive disorder characterized by sparse and short hair, heralding progressive degeneration of the retinal pigment epithelium, which leads to blindness by the second decade of life. The disorder is caused by mutations in CDH3, a gene encoding P-cadherin, a major component of adherens junctions. Most HJMD cases reported to date have been shown to be caused by homozygous CDH3 mutations segregating in consanguineous families.

AIM AND METHODS

To elucidate the genetic basis of HJMD in two nonconsanguineous families, we established the coding sequence of CDH3 in four patients and their healthy siblings.

RESULTS

The four patients demonstrated markedly variable degrees of visual acuity impairment. Novel biallelic recessive mutations were identified in all affected individuals. One patient in the first family was found to carry two heterozygous mutations, IVS2 + 1G-->A and p.E504K; the other three patients in the second family were compound heterozygous for a missense mutation, p.H575R, and a nonsense mutation, p.R221X.

CONCLUSION

This paper expands the spectrum of known mutations in CDH3 and points to the existence of clinical heterogeneity in this syndrome.

Diabetes care in extended-care facilities: appropriate intensity of care?

OBJECTIVE

The American Diabetes Association (ADA) does not recognize different treatment goals for the institutionalized adult compared with the outpatient adult with diabetes, nor has it outlined specific recommendations for this population. The purpose of this study was to examine physician management of patients with type 1 and type 2 diabetes residing in extended-care facilities and to compare this management with ADA standards of care for the outpatient adult.

RESEARCH DESIGN AND METHODS

This retrospective chart review included data from 108 residents with type 1 or type 2 diabetes at 11 extended health care facilities in the Midwestern U.S. and included a review of the medical problem list, medication list, laboratory reports, and all physician and consultation notes during the study period.

RESULTS

Blood glucose was monitored in 98% of the subjects, and 38% met glucose goals. A1C goal was achieved in 67% of patients. Blood pressure was monitored in 94% of patients, with 55% meeting goal. Thirty-one percent of patients had yearly lipids checked, 37% had annual electrocardiograms, 7% had urine analyzed for microalbuminuria, 42% were on aspirin, 87% received foot exams, 42% received dilated eye exams, 89% received influenza vaccinations, and 46% received pneumoccocal vaccinations.

CONCLUSIONS

Care of the institutionalized elderly with diabetes fails to meet ADA standards of care for the outpatient adult. Separate practice guidelines are needed for people with diabetes who reside in extended care facilities in order to improve quality and consistency of care.

Effective handling of health-related leaves of absence

This article will address the legal obligations of employers in non-union settings toward employees who request pregnancy leave, parental or medical leave, workers' compensation leave, and other forms of disability leave. Specifically, this article will address the legal standards set forth under the Pregnancy Discrimination Act, various state pregnancy and family leave acts, workers' compensation retaliatory discharge authority, and the Americans With Disabilities Act of 1990. In addition, this article will provide practical guidance for employers in formulating effective leave policies that provide the maximum amount of operational flexibility while at the same time minimizing the risk of costly and excessive litigation.

Hirsutism. Pathophysiology, clinical evaluation, treatment

Hirsutism is generally an androgen-mediated disorder. Tremendous progress has been made in elucidating the numerous clinical disorders that can cause it. Systematic evaluation of hirsute women must be directed at determining the cause of hyperandrogenemia, which in turn allows specific and effective therapy to be initiated.