CORRELATION OF SPINOPELVIC PARAMETERS WITH DISABILITY STATUS IN PATIENTS WITH DEGENERATIVE LUMBAR DISEASES

Lumbar degenerative disease usually manifests in spine clinics. This study examines the spino-pelvic characteristics of lumbar degenerative disease patients as well as the clinical ramifications in the Indian population which help in early identification of sagittal spine anomalies. Purpose - to study the spinopelvic parameters and correlate them with disability status in patients with degenerative lumbar diseases. This cross-sectional observational study focused on patients aged 40 to 60, diagnosed with degenerative lumbar spine diseases, seen at the Orthopedics Outpatient Department. Thorough history, clinical examination, and disability assessment were conducted using the modified Oswestery Disability Questionnaire (ODI). Radiological evaluation included measuring spinopelvic parameters-Pelvic Incidence (PI), Pelvic Tilt (PT), Sacral Slope (SS), and Lumbar Lordosis (LL)-correlated with disability. Disability status was determined through the Oswestry Low Back Pain Disability (ODI) Questionnaire. Among the study population, the difference in mean of Pelvic Tilt, Sacral slope, Lumbar lordosis, Pelvic incidence across disability status was not statistically significant. BMI and sacral slope showed positive correlation to sacral slope and negative correlation to Pelvic Tilt, Lumbar Lordosis, ODI. This study concluded there was no association between spinopelvic characteristics and level of disability in degenerative lumbar disease. Early detection of spinopelvic changes can aid in early intervention, slow down disease progression, and lessen impairment brought on by degenerative disc diseases.

Structure of quantum supercooled liquids

Supercooled liquids show a drastic slowdown in the dynamics with decreasing temperature, while their structure remains similar to that of normal liquids. In this paper, the structural features in a quantum supercooled liquid are explored in terms of cages defined using the Voronoi polyhedra and characterized in terms of their volumes and geometries. The cage volume fluctuations are sensitive to the quantum effects, and decrease as the glass transition is approached by varying the quantumness. This is in contrast to the classical case where the volumes are insensitive to temperature variations as one approaches the transition. The cage geometry becomes more spherical upon increasing quantumness from zero, pushing the system closer to the glass transition. The cage geometry is found to be significantly correlated with asymmetry in the position uncertainty of the caged particle in the strongly quantum regime.

Real-World User and Clinician Perspective and Experience with MiniMed™ 780G Advanced Hybrid Closed Loop System

INTRODUCTION

The advanced hybrid closed loop (AHCL) MiniMed™ 780G system changes basal insulin delivery every 5 min and auto bolus in response to sensor glucose values. We assessed the performance of the AHCL system in real-world settings for individuals with type 1 diabetes (T1DM) as well as user and clinician perspectives and satisfaction.

METHODS

We held two peer group discussions: one having adults with T1DM/parents of children and adolescents with T1DM to understand their experiences with the AHCL system and another with healthcare providers (HCPs). Responses from the discussions were analyzed and categorized into themes by two independent researchers, with any inconsistencies resolved by consensus. We also analyzed data from the system uploaded to CareLink personal software. Glycemic outcomes, including time in range (TIR), time below range (TBR), time above range (TAR), mean sensor glucose (SG) levels, glucose management indicator (GMI), sensor use, and percentage of time spent in AHCL, were determined.

RESULTS

The peer group discussions revealed numerous key themes and issues for each group, such as the significance of setting reasonable expectations, carbohydrate counting and bolus dosing, technical difficulties, and overall user experience. The users (n = 25; T1DM; 17 female; age 13.8 ± 7.49 years; A1C 6.54 ± 0.45%; duration of diabetes 6 ± 6.78 years) were very satisfied with the system. Most users experienced consistent blood glucose values with very few hypoglycemic episodes. However, there were a few limitations reported, such as hyperglycemic episodes caused by inaccuracies in carb counting, issues with sensor connectivity, and cannula blockages or kinking for those using insulin Fiasp. Users achieved a mean GMI of 6.4 ± 0.26%, TIR of 83.0 ± 8.12%, TBR (54-70 mg/dL) of 2.0 ± 0.81%, TBR* (< 54 mg/dL) of 0%. All of the users achieved a TIR of > 70%.

CONCLUSION

The use of the AHCL system in T1DM resulted in robust glycemic control, minimizing hypoglycemia. Providing training to both users and HCPs can help them use the system effectively.

Critical Appraisal of Paediatric Embryonal Cancers Treated with Image-guided Intensity-modulated Proton Therapy

AIM

To carry out a comprehensive critical appraisal of image-guided intensity-modulated proton therapy practice for craniospinal irradiation (CSI).

MATERIALS AND METHODS

An image-guided intensity-modulated proton therapy database of 45 consecutive paediatric patients with central nervous system embryonal malignancies treated between January 2019 and April 2022 were critically appraised for demography, diagnosis, treatment planning strategy and treatment delivery accuracy.

RESULTS

Most patients (median age: 7.5 years; male:female ratio: 34:11) had medulloblastoma (56%), followed by recurrent ependymoma (19%), pinealoblastoma (5%), germ cell (5%) and others (15%). The dose to the planning target volume-craniospinal (PTV-CS; length 39.06-79.59 cm) varied from 21 to 35 GyRBE, whereas the combined median dose to craniospinal and boost was 54 GyRBE. In all patients, the 95% isodose line covered the cribriform plate completely and optic nerves mostly, with a median V95% of 100% and 82.96%, keeping Dmax to the lens <3.9 GyRBE. In skeletally immature patients (88.38%), the anterior vertebral body was completely covered in 18.18% and underdosed in 70.15% of the cases, resulting in a median Dmean of 10.11 GyRBE to the oesophagus. Lateral spine coverage was maintained on the edges of the vertebral body in 52.2%, whereas it extended beyond in 48.8%. The median V98% for clinical target volumes and V95% for PTVs of the brain, spine and craniospinal were >97%, with excellent conformity (0.89) and homogeneity (0.07) indices for PTV-CS. All neurological organs at risk received a median Dmax ranging from 36 to 44 GyRBE from the combined CSI and boost regimens. Analysis of patient-specific quality assurance results revealed that 545 (97.67%) planar dosage verification had gamma (3% at 3 mm) values >95%. The online patient set-up verification showed translational and rotational deviation within 2 mm and 0.5° in 88-94% and 97% of the cases. Systematic and random error were within 0.90 mm and 1.71 mm in translation and 0.1° and 0.2° in rotation.

CONCLUSION

A change in practice pattern was observed. The findings from our comprehensive critical appraisal add to the growing library of CSI practice and may serve as a reference for inter-institutional comparison.

Human Digital Twin for Personalized Elderly Type 2 Diabetes Management

Managing Elderly type 2 diabetes (E-T2D) is challenging due to geriatric conditions (e.g., co-morbidity, multiple drug intake, etc.), and personalization becomes paramount for precision medicine. This paper presents a human digital twin (HDT) framework to manage E-T2D that exploits various patient-specific data and builds a suite of models exploiting the data for prediction and management to personalize diabetes treatment in E-T2D patients. These models include mathematical and deep-learning ones that capture different patient aspects. Consequently, the HDT virtualizes the patient from different viewpoints using an HDT that mimics the patient and has interfaces to update the virtual models simultaneously from measurements. Using these models the HDT obtains deeper insights about the patient. Further, an adaptive patient model fusing this information and a learning-based model predictive control (LB-MPC) algorithm are proposed. The geriatric conditions are captured as model parameters and constraints while solving the LB-MPC to personalize the insulin infusion for E-T2D management. The HDT is deployed on and illustrated with 15 patients using clinical trials and simulations. Our results show that HDT helps improve the time-in-range from 3–75% to 86–97% and reduces insulin infusion by 14–29%.

Comparing the benefits of applying a vacuum assisted lancing device in reducing lancing pain, improving self-monitoring frequency and reducing HbA1c in people with diabetes

BACKGROUND AND AIMS

For most people with diabetes (PwD), lancing fingertips for obtaining a blood sample is unavoidable during blood glucose monitoring (BGM). This study investigated the potential benefits of applying a vacuum over the penetration site immediately, before, during, and after lancing to determine if a vacuum would allow a less painful lancing process from fingertips and alternate sites, while still drawing sufficient blood, thereby allowing PwD to have a painless lancing experience and improving self-monitoring frequency. The cohort was encouraged to use a commercially available vacuum assisted lancing device. Change in pain perception, testing frequency, HbA1c, and future probability of VALD use were determined.

METHODS

In a 24-week randomized open-label, interventional, cross-over trial, 110 PwD were recruited who used VALD and non-vacuum conventional lancing devices, for 12 weeks each. Percentage reduction in HbA1c, percentage BGM adherence, scores of pain perception, and probability of selecting VALD in the future were measured and compared.

RESULTS

There was reduction in overall HbA1c values (mean ± SD), (from 9.01 ± 1.68% at baseline to 8.28 ± 1.66%) and individually in T1D (from 8.94 ± 1.77% to 8.25 ± 1.67%) and T2D (from 8.31 ± 1.17% to 8.59 ± 1.30) after using VALD for 12 weeks. Lower pain perception and high probability of using VALD over conventional devices were observed.

CONCLUSION

The study highlights the benefits of applying a vacuum to the lance site which enhances the effectiveness in reducing and eliminating pain, improving self-monitoring frequency, and lowering HbA1c over non-vacuum conventional devices.

A systematic review on pharmacist-led pharmaceutical care optimization through virtual platforms

Objectives

To display virtual pharmaceutical care programs implemented by pharmacists across the world. Accordingly, a search in PubMed, Scopus and Embase with keywords such as ‘'Pharmacist', ‘Pharmaceutical care’, ‘Virtual platform’ and its associated medical subject headings retrieved appropriate articles. The quality of each filtered article were assessed with the Critical Appraisal Skills Program checklist.

Key findings

A total of 2 14 841 articles were identified through database screening and 16 articles were extracted and finalized. Twelve papers presented different forms of electronic medical record-based virtual pharmacy systems that had significantly contributed to patient care; minimizing medication errors, rectifying adverse events, modifying drug administration patterns to reduce the fatality of drug–drug interaction and further promoting medication counselling. Nevertheless, few studies had social media platforms for providing clinical pharmacy services that depicted good patient satisfaction. Additionally, we were also able to portray community pharmacies that transformed themselves to provide better and easily accessible pharmaceutical care to their society.

Summary

There are limited numbers of peer-reviewed articles on pharmacist-operated virtual systems. However, owing to the benefits imparted to patient safety and care by the virtual pharmacy in the era of pandemic, it is highly recommended that more pharmacy professionals contribute and implement such programs in their settings.

Prospero Registration ID

CRD42022307175.

Validation of the TNM-8 AJCC classification for HPV-positive oropharyngeal cancers in patients undergoing trans-oral robotic surgery

High-risk human papillomaviruses (HPV) are associated with some oropharyngeal squamous cell carcinomas (OPSCC). HPV-OPSCC have better survival outcomes compared to HPV negative tumours. The new TNM-8 AJCC staging (2018) is based on ICON-S data with 98% of patients treated with primary chemoradiation. To validate the TNM-8 AJCC classification in HPV-OPSCC treated primarily with surgery (trans-oral robotic surgery or open). There were 102 patients with HPV-OPSCC treated between July 2009 and December 2014 at the Royal Adelaide Hospital. The median age was 57 years (range: 38-83) and mostly males (84.5%). 27.2% were active smokers and 50.5% reformed smokers. Early T-stage cancer in 72.8%. Primary treatment was surgery & adjuvant therapy (70%) while primary chemoradiation (30%). Survival analyses were performed for the 7th and 8th AJCC systems. The reclassification to the AJCC 8th edition staging system resulted in a change of 54 patients from stage 4 to stages 1 and 2. This was mainly an effect of changes with N2a and N2b nodal disease being reclassified to N1. Survival outcomes were comparable with the ICON-S data. The new TNM-8 classification is, therefore, validated in a cohort treated, predominantly, with primary surgery and adjuvant therapy.

Empowering Patients with Type 1 Diabetes through a Multidisciplinary Team-assisted, Technology-Enabled Education Program

BACKGROUND

Carbohydrate counting is a tool that helps patients with type 1 diabetes (T1D) to control their blood glucose. It calculates the bolus insulin dose needed from the total amount of carbohydrates consumed at each meal. However, carbohydrate counting can be quite challenging. The Diabetes Tele Management System® (DTMS®) is a telemedicine-based program that enables the patient to interact directly with a professionally trained, multidisciplinary team (MDT) of experts. This, along with technology-enabled education programs, could allow people with T1D to achieve glycemic control.

METHODS

Fifty patients with T1D between 5 and 35 years with a diabetes duration of at least 6 months, baseline HbA1c of 7 or above, using SCII or MDI and willing to take part in the study were invited to participate in an MDT-assisted technology-enabled program and trained trimonthly on carbohydrate counting. The control group went on to perform carbohydrate counting independently and used technologies at their convenience. The test group additionally received continuous individual assistance from the MDT.

RESULTS

The MDT-assisted patients had significantly decreased HbA1c, blood glucose levels, decreased episodes of hyperglycemia and hypoglycemia, and reported a more positive outlook on life.

CONCLUSION

Carbohydrate counting remains a challenge for youth with T1D, and errors in counting can have a clinical impact. Our data suggested that the assistance from an MDT of experts was associated with improved carbohydrate counting, which led to improved glycemic control and reduced complications.

Quantum uncertainty effects in the dynamics of supercooled liquids: A molecular dynamics study

Dynamics of density fluctuations in quantum supercooled liquids is analyzed using molecular dynamics simulations. In contrast to the classical case, the uncertainty in the particle position (delocalization of quantum particle in space) leads to significant differences in the dynamics of quantum liquids, both in the short- and long-time limits. The effect of uncertainty is found to be significant for length scales smaller than the uncertainty itself, and diminishes as the length scale grows. The dynamic heterogeneity of the system at short times is enhanced due to uncertainty. In the intermediate (β-relaxation) time regime, the heterogeneity tends to get suppressed due to quantum uncertainty. The probability distribution of particle displacements shows highly nonclassical behavior with double-peak structure at short timescales.

Tagged particle dynamics in supercooled quantum liquids

We analyze the dynamics of quantum supercooled liquids in terms of tagged particle dynamics. Unlike the classical case, uncertainty in the position of a particle in quantum liquid leads to qualitative changes. We demonstrate these effects in the dynamics of the first two moments of displacements, namely, the mean-squared displacement, 〈Δr^{2}(t)〉, and 〈Δr^{4}(t)〉. Results are presented for a hard-sphere liquid using mode-coupling theory formulation and simulation on a binary Lennard-Jones liquid. As the quantumness (controlled by the de Broglie thermal wavelength) is increased, a nonzero value of the moments at zero time leads to significant deviations from the classical behavior in the initial dynamics. Initial displacement shows ballistic behavior 〈Δr^{2}(t)〉∼t^{2}, but, as a result of large uncertainty in the position, the dynamical effects become weaker with increasing quantumness over this timescale.

Type 2 Diabetes in Women: Differences and Difficulties

BACKGROUND

Lifestyle modification, along with medication, has improved the quality of life of patients with type 2 diabetes (T2D), but the treatment of diabetes in women still lacks a gender-centric approach.

METHODS

Expert opinions to improve diabetes management in women were collated from the open discussion forum organized by the sixth Jothydev's Professional Education Forum Diabetes Convention, which included global diabetes care experts and the general public. The review is also based on the studies published in electronic databases such as PubMed and Google Scholar that discussed the problems and challenges faced by the Indian diabetes care sector in treating women with diabetes.

RESULTS

The complex interplay of biological, socioeconomic, psychosocial, and physiological factors in women with type 2 diabetes has not been well addressed to date. Biological factors such as neurohumoral pathways, sex hormones, genetic predisposition as well as gender-based environmental and behavioural differences must be considered for modern personalized diabetes treatment. Most importantly, pregnant women with diabetes deserve special attention. This vulnerable phase has a marked impact on the future health of both the mother and the offspring.

CONCLUSION

The review provides an overview of the challenges and issues that exist in the clinical management of diabetes and its complications among women in India. Women-centric clinical approaches should be encouraged for the effective management of diabetes in Indian women.

Goat as the ideal climate-resilient animal model in tropical environment: revisiting advantages over other livestock species

In the agriculture sector, livestock are considered extremely resilient to climate change and are tipped to play a significant role in ensuring food security to meet the increased demands of growing human population by 2050. Compared to other domestic species, goats are considered the ideal animal model for climate change due to its high thermal and drought resilience, ability to survive on limited pastures, and high disease resistance. This review is therefore a revisit to the advantages of rearing goats over other livestock species under current and future trends of changes in climate, particularly to cope with recurrent multiple stressors such as heat load, and lack of water and feed. In summary, goats, also called as poor man's cow, are preferred by the small-scale landless farmers due to their low input and assured higher output system, as they require low initial investment, with minimum specialized facilities and labors. Furthermore, they perceive goats as better resilient animal to cope with multiple stressors such as heat load, and water and feed scarcity, and possess better skills to cope with bush, when compared with sheep and cattle. The unique capacity for employing behavioral plasticity and morphological features of goats gives them clear advantage over sheep and cattle, when coping with seasonal biotopes, and experiences of water and feed shortage. When facing with low-quality feed, they also are superior to cattle and sheep to digest dry matter and to recycle nitrogen. Additionally, goats have superior ability to desiccate feces and concentrate urine, when compared with sheep and cattle. These advantages make goat the go-to species for efficiently countering the adversities associated with climate change and to optimize appropriate economic return through sustained production. Therefore, goats are tipped to be the future animals with extreme potential to counter the projected alarming climate change impacts and expected to play a significant role in ensuring food security to meet the demands of the growing human population by the end of this century.

COVID-19 associated mucormycosis: A Descriptive Multisite Study from India

BACKGROUND AND AIMS

Mucormycosis is an invasive fungal infection and carries a significant morbidity and mortality. A number of cases of mucormycosis have been reported in association with COVID-19. In this study, a consortium of clinicians from various parts of India studied clinical profile of COVID-19 associated mucormycosis (CAM) and this analysis is presented here.

METHODS

Investigators from multiple sites in India were involved in this study. Clinical details included the treatment and severity of COVID-19, associated morbidities, as well as the diagnosis, treatment and prognosis of mucormycosis. These data were collected using google spreadsheet at one centre. Descriptive analysis was done.

RESULTS

There were 115 patients with CAM. Importantly, all patients had received corticosteroids. Diabetes was present in 85.2% of patients and 13.9% of patients had newly detected diabetes. The most common site of involvement was rhino-orbital. Mortality occurred in 25 (21.7%) patients. On logistic regression analysis, CT scan-based score for severity of lung involvement was associated with mortality.

CONCLUSION

Universal administration of corticosteroids in our patients is notable. A large majority of patients had diabetes, while mortality was seen in ∼1/5th of patients, lower as compared to recently published data.

A new interventional home care model for COVID management: Virtual Covid IP

AIM

Amidst COVID-19 pandemic, the health care delivery in India faces major challenges owing to the overwhelming hospitals, exhausted healthcare workers, and shortage of crucial medical supplies such as ventilators and oxygen. The study aims to propose a novel successful interventional home care model, the Virtual COVID In-Patient (VCIP) care for effective COVID management.

METHODS

The Covid-19 positive patients enrolled in VCIP were chosen for the study. A 24/7 active multidisciplinary WhatsApp group was created for each patient, for remote monitoring of temperature, blood pressure, blood glucose, respiratory and pulse rate along with the symptoms. Advice on sleep and exercises were given along with the medication via video-audio consultations. Lab facility was provided at the doorstep. Training on various devices, medications including steroids, delivering subcutaneous injections etc were given via video platforms.

RESULTS

Among the 220 patients who availed the VCIP facility, only two were hospitalized, yielding a 99.5 % success rate in preventing hospitalizations and patients enrolled have been immensely satisfied with their experience.

CONCLUSIONS

With similar pandemics anticipated in near future, VCIP model may be considered for successful domiciliary treatment and overcoming the challenges.

Body status and blood metabolites profiles during resumption of postpartum ovarian activity in yak (Poephagus grunniens)

We examined the changes in body weight (BW), back-fat thickness (BFT) and blood metabolites in relation to postpartum (PP) ovarian activity status in twenty female yaks raised under semi-intensive system. BFT and ovarian activities, like follicle development, ovulation (OV) and corpus luteum (CL) development, were monitored from 4 to 15 weeks (wk) PP using ultrasonography. Resumption of ovarian activity was confirmed with ovulation of dominant follicle (DF) and subsequent CL development, and >1 ng/ml progesterone concentration in blood plasma sample after 1week of ovulation. Yaks were further classified as cyclic (with CL), acyclic (without CL), and cystic (with >25 mm follicular cyst; FC). Within 20 weeks PP, 60% yaks resumed cyclic ovarian activity, while 25% failed to initiate cycling activity, and 15% developed follicular cysts. In all categories of yak, BW gradually decreased (p < .05) till nadir; however, nadir reached earlier (p < .05) in acyclic yaks. BFT differed (p < .05) among the yak groups, but it tended to be higher in cyclic yaks as compared to acyclic and cystic. No difference (p > .05) in non-esterified fatty acids (NEFA) values was found among the different categories of yaks, whereas, beta-hydroxy butyrate (BHB) levels were higher in cystic animals as compared to acyclic and cyclic. Blood glucose levels decreased in all yaks during initial 2 weeks after calving. Our findings suggest that yaks with low BW, BFT and glucose levels, and higher BHB values were at risk of delayed resumption of ovarian activity and concomitant development of follicular cysts.

Management Strategies for Dealing With Surges of the COVID-19 Pandemic

The spread of COVID-19 (coronavirus disease 2019) across the world has resulted in widespread morbidity and mortality. An explosive increase in the number of cases during the surge phase of the pandemic can result in a management crisis. Therefore, we propose a simple model to manage the surges of the pandemic.

Time-in-range as a target in type 2 diabetes: An urgent need

Time-in-range emerged as a valuable blood glucose metric, 'beyond HbA1c' for a deeper insight into glycemic control in people with diabetes. It denotes the proportion of time that a person's glucose level remains within the desired target range (usually 70-180 mg/dL or 3.9-10.0 mmol/L). Though clinical targets in the current recommendations for type 1 and type 2 diabetes are close enough, their clinical profiles and prevalences are quite different. Type 2 diabetes is the commonest form of diabetes. Many clinical trials have challenged the usefulness of HbA1c as a glycemic target for Type 2 diabetes mellitus. On account of the higher prevalence and complications of type 2 diabetes, more outcomes-based studies are needed to associate time-in-range with its ongoing risk. These studies strongly support the dependability of time-in-range to identify patients with elevated risk in type 2 diabetes. We discuss the utility of time-in-range, a new metric of continuous glucose monitoring as an outcome measure to correlate with type 2 diabetes risks and complications and to analyze the effectiveness of type 2 diabetes management. This approach may support the use of time-in-range as a metric for long-term health outcomes in the type 2 diabetes population.

Digital health and diabetes: experience from India

The digitization of healthcare and its usage in the delivery of healthcare have experienced exponential growth across the world in recent times. India's fast-growing diabetes population has been exerting immense pressure on the country's healthcare infrastructure. Various innovative and evolving technologies are converging to impact the trajectory of digital health in diabetes. The diabetes community has been adopting various technologies such as connected glucose meters, continuous glucose monitoring systems, continuous subcutaneous insulin infusion, closed-loop systems, digitalization of health data, and diabetes-related apps for the prevention and management of the condition. India has provided some excellent examples in exploiting the potential of digital transformation in revamping the diabetes ecosystem. Yet, there are still various hurdles in technology development, healthcare delivery, as well as concerns related to data privacy, digital divide, policies by the government, role of stakeholders, attitude, and absorption by healthcare professionals, and hospitals. This article provides an overview of the digital diabetes technologies currently practiced in India and recommends the need for strong technology adaptation and policy interventions for an ideal roadmap of digitalization of diabetes care in the Indian milieu.

The Do-It-Yourself Artificial Pancreas: A Comprehensive Review

Diabetes technology (DT) has accomplished tremendous progress in the past decades, aiming to convert these technologies as viable treatment options for the benefit of patients with diabetes (PWD). Despite the advances, PWD face multiple challenges with the efficient management of type 1 diabetes. Most of the promising and innovative technological developments are not accessible to a larger proportion of PWD. The slow pace of development and commercialization, overpricing, and lack of peer support are few such factors leading to inequitable access to the innovations in DT. Highly motivated and tech-savvy members of the diabetes community have therefore come up with the #WeAreNotWaiting movement and started developing their own do-it-yourself artificial pancreas systems (DIYAPS) integrating continuous glucose monitoring (CGM), insulin pumps, and smartphone technology to run openly shared algorithms to achieve appreciable glycemic control and quality of life (QoL). These systems use tailor-made interventions to achieve automated insulin delivery (AID) and are not commercialized or regulated. Online social network megatrends such as GitHub, CGM in the Cloud, and Twitter have been providing platforms to share these open source technologies and user experiences. Observational studies, anecdotal evidence, and real-world patient stories revealed significant improvements in time in range (TIR), time in hypoglycemia (TIHypo), HbA1c levels, and QoL after the initiation of DIYAPS. But this unregulated do-it-yourself (DIY) approach is perceived with great circumspection by healthcare professionals (HCP), regulatory bodies, and device manufacturers, making users the ultimate risk-bearers. The use of the regularized CGM and insulin pump with unauthorized algorithms makes them off-label and has been a matter of great concern. Besides these, lack of safety data, funding or insurance coverage, ethical, and legal issues are roadblocks to the unanimous acceptance of these systems among patients with type 1 diabetes (T1D). A multi-agency approach is necessary to evaluate the risks, and to delineate the incumbency and liability of clinicians, regulatory bodies, and manufacturers associated with the use of DIYAPS. Understanding the potential of DIYAPS as the need of the present time, many regional and international agencies have come with strategies to appraise its safety as well as to support education and training on its use. Here we provide a comprehensive description of the DIYAPS-including their origin, existing literature, advantages, and disadvantages that can help the industry leaders, clinicians, and PWD to make the best use of these systems.

Evolution of Insulin Delivery Devices: From Syringes, Pens, and Pumps to DIY Artificial Pancreas

The year 2021 will mark 100 years since the discovery of insulin. Insulin, the first medication to be discovered for diabetes, is still the safest and most potent glucose-lowering therapy. The major challenge of insulin despite its efficacy has been the occurrence of hypoglycemia, which has resulted in sub-optimal dosages being prescribed in the vast majority of patients. Popular devices used for insulin administration are syringes, pens, and pumps. An artificial pancreas (AP) with a closed-loop delivery system with > 95% time in range is believed to soon become a reality. The development of closed-loop delivery systems has gained momentum with recent advances in continuous glucose monitoring (CGM) and computer algorithms. This review discusses the evolution of syringes, disposable, durable pens and connected pens, needles, tethered and patch insulin pumps, bionic pancreas, alternate controller-enabled infusion (ACE) pumps, and do-it-yourself artificial pancreas systems (DIY-APS).

Summer season induced changes in quantitative expression patterns of different heat shock response genes in Salem black goats

Research efforts of elucidating the molecular mechanisms governing heat shock response which imparts thermo-tolerance ability to indigenous breeds are very scanty. Therefore, a study was conducted with the primary objective to determine the impact of heat stress on the expression pattern of different heat shock response genes in the hepatic tissues of indigenous Salem Black goat. The study was conducted for a period of 45 days in twelve 1-year-old female Salem Black breed goats. The animals were randomly allocated into two groups of six animals each, C (n = 6; Salem Black control) and HS (n = 6; Salem Black heat stress). The C animals were maintained in the shed in comfort condition while HS animals were exposed outside to summer heat stress between 10:00 h to 16:00 h during experimental period. The animals were slaughtered at the end of study and their liver samples were collected for assessing the different heat shock response genes. Based on the results obtained from the study it was established that the heat shock protein 70 (HSP70), HSP90, super oxide dismutase (SOD), nitrous oxide synthase 1 (NOS1) genes were significantly (P < 0.05) down regulated. However, heat stress did not influence the expression pattern of heat shock factor-1 (HSF1) gene. The lower level of expression of all heat shock response genes may be due to less magnitude of heat stress in the study to induce cellular stress response in Salem Black goats.

Prediction models, assessment methodologies and biotechnological tools to quantify heat stress response in ruminant livestock

Livestock industries have an important role in ensuring global food security. This review discusses the importance of quantifying the heat stress response of ruminants, with an emphasis on identifying thermo-tolerant breeds. There are numerous heat stress prediction models that have attempted to quantify the response of ruminant livestock to hot climatic conditions. This review highlights the importance of investigating prediction models beyond the temperature-humidity index (THI). Furthermore, this review highlights the importance of incorporating other climatic variables when developing prediction indices to ensure the accurate prediction of heat stress in ruminants. Prediction models, particularly the heat load index (HLI) were developed to overcome the limitations of the THI by incorporating ambient temperature (AT), relative humidity (RH), solar radiation (SR) and wind speed (WS). Furthermore refinements to existing prediction models have been undertaken to account for the interactions between climatic variables and physiological traits of livestock. Specifically, studies have investigated the relationships between coat characteristics, respiration rate (RR), body temperature (BT), sweating rate, vasodilation, body weight (BW), body condition score (BCS), fatness and feed intake with climatic conditions. While advancements in prediction models have been occurring, there has also been substantial advancement in the methodologies used to quantify animal responses to heat stress. The most recent development in this field is the application of radio frequency identification (RFID) technology to record animal behaviour and various physiological responses. Rumen temperature measurements using rumen boluses and skin temperature recording using infrared thermography (IRT) are making inroads to redefine the quantification of the heat stress response of ruminants. Further, this review describes several advanced biotechnological tools that can be used to identify climate resilient breeds of ruminant livestock.

The impact of heat stress on the immune system in dairy cattle: A review

Heat stress is well documented to have a negative influence on livestock productivity and these impacts may be exacerbated by climate change. Dairy cattle can be more vulnerable to the negative effects of heat stress as these adverse impacts may be more profound during pregnancy and lactation. New emerging diseases are usually linked to a positive relationship with climate change and the survival of microrganisms and/or their vectors. These diseases may exaggerate the immune suppression associated with the immune suppressive effect of heat stress that is mediated by the hypothalamic-pituitary-adrenal (HPA) and the sympathetic-adrenal-medullary (SAM) axes. It has been established that heat stress has a negative impact on the immune system via cell mediated and humoral immune responses. Heat stress activates the HPA axis and increases peripheral levels of glucocorticoids subsequently suppressing the synthesis and release of cytokines. Heat stress has been reported to induce increased blood cortisol concentrations which have been shown to inhibit the production of cytokines such as interleukin-4 (IL-4), IL-5, IL-6, IL-12, interferon γ (IFNγ), and tumor necrosis factor-α (TNF- α). The impact of heat stress on the immune responses of dairy cows could be mediated by developing appropriate amelioration strategies through nutritional interventions and cooling management. In addition, improving current animal selection methods and the development of climate resilient breeds may support the sustainability of livestock production systems into the future.

Effect of heat stress on the quantitative expression patterns of different cytokine genes in Malabari goats

A study was conducted to determine the influence of exposure to hot environment on different cytokine gene expression patterns in Malabari goat. The study was conducted in 12 (10 months to 1 year old) goats of Malabari breed for 45-day duration. The control (n = 6; C) group goats were kept under comfortable condition in the shaded pens while heat stress (n = 6; HS) group goats were kept out in the open hot environment during summer season for the study duration between 10.00 h to 16.00 h. The representative mesenteric lymph node (MLN) samples were collected from the slaughtered goats at the end of study for assessing the different cytokine gene expression and histopathological changes. Compared with C group, the expression patterns of interleukin 18 (IL-18), tumor necrosis factor-α (TNF-α), interferon-β (IFN-β), and IFN-γ downregulated (P < 0.05) in the HS group. The histopathological changes of MLNs showed paucity of lymphocyte distribution in follicular areas as wells as decreased density of lymphocytes in the germinal centers of the HS group (P < 0.05). The findings from this study reflected the compromised immune functions during heat stress in Malabari goats. Further, the study established that IL-18, TNF-α, IFN-β, and IFN-γ genes could serve as reliable immunological markers for quantifying heat stress-mediated immune response alterations in Malabari goats.

Identification and expression profiling of MSY genes of yak for bull fertility

Yak (Bos grunniens) is a unique bovine species and considered as lifeline of highlanders. The male subfertility in yak is a matter of concern that causes huge economic loses. The spermatogenesis and male reproduction machinery are critically governed by Y-linked genes which tend to acquire necessary information in the course of evolution. The Y-linked fertility genes are present in multiple copies with testis-limited expression. To understand this novel complexity, 12 male-specific region of Y chromosome (MSY) genes have been studied in the yak. Targeted genes are amplified in male and female genomic DNA and confirmed the male derived specificity. Moreover, testis and sperm-specific expressions of MSY genes are distinct among different tissues. The quantitative polymerase chain reaction results validate the expression pattern of these genes in various tissues with predominant expression intestis and sperm. The sequencing of resultant yak MSY genes gives significant result and shows similarity with cattle (Bos indicus), but few nucleotide mismatches define the proposition of infertile male in the F₁ hybrid of cattle and yak. The identified MSY genes can be used to establish male-specific characteristics and to differentiate male and female yak genotypically. Further, these genes may act as valuable resources to understand the capacity of spermatogenesis, embryogenesis, cellular growth, azoospermia and malesubfertility in the yak.

Heat stress impact on the expression patterns of different reproduction related genes in Malabari goats

A study was conducted to evaluate the effect of heat stress on the expression pattern of reproduction related genes in Malabari breed of goat. The study was conducted during 45 days using twelve 10 months to one year old Malabari goats. The goats were randomly allocated into two groups: MC (n = 6; Malabari control) and MHS (n = 6; Malabari heat stress). Goats were stall-fed with a diet composed of 60% roughage and 40% concentrate. All animals had access to ad-libitum feed and water and they were fed and watered individually. The MC goats were placed in the shaded pens while MHS goats were exposed to heat stress in outside environment between 10.00 h and 16.00 h. At the end of study period, all 12 animals were slaughtered and their uterus tissues were collected for gene expression and histopathological studies. The temperature humidity index (THI) inside shed (74.9) proved that the animals were not stressed while in the outside environment (86.5) the animals were extremely distressed. Heat stress significantly (P < 0.05) influenced the expression patterns of follicle stimulating hormone receptor (FSHR), luteinizing hormone receptor (LHR), estrogen receptor α (ESTRα), prostaglandin F2 α (PGF2α) and cyclooxygenase-2 (COX-2). However, prostaglandin E2 (PGE2) did not differed between the groups. Further, a strong positive correlation (P < 0.01) was established for THI with both FSHR gene expression. A negative correlation was also established between THI and ESTRα (P < 0.01), PGF2α (P < 0.01), PGE2 (P < 0.05) genes. However, heat stress did not influence the expression patterns of LHR; COX-2 genes. The histopathological section of uterine epithelial cells showed degenerative changes (P < 0.05) with less differentiation in MHS group as compared to MC group. The results from the study clearly indicated that heat stress was able to alter the reproductive activity related gene expressions at uterine level and this could be an indication of reduced reproductive efficiency in Malabari goats.

Establishing gene Amelogenin as sex-specific marker in yak by genomic approach

Yak, an economically important bovine species considered as lifeline of the Himalaya. Indeed, this gigantic bovine is neglected because of the scientific intervention for its conservation as well as research documentation for a long time. Amelogenin is an essential protein for tooth enamel which eutherian mammals contain two copies in both X and Y chromosome each. In bovine, the deletion of a fragment of the nucleotide sequence in Y chromosome copy of exon 6 made Amelogenin an excellent sex-specific marker. Thus, an attempt was made to use the gene as an advanced molecular marker of sexing of the yak to improve breeding strategies and reproduction. The present study confirmed that the polymerase chain reaction amplification of the Amelogenin gene with a unique primer is useful in sex identification of the yak. The test is further refined with qPCR validation by quantifying the DNA copy number of the Amelogenin gene in male and female. We observed a high level of sequence polymorphisms of AMELX and AMELY in yak considered as novel identification. These tests can be further extended into several other specialized fields including forensics, meat production and processing, and quality control.

Resilience of three indigenous goat breeds to heat stress based on phenotypic traits and PBMC HSP70 expression

The objective of this experiment was to evaluate the influence of summer heat stress on physiological and behavioral responses of Osmanabadi, Salem Black, and Malabari goats. The study also evaluated the differences in heat shock protein 70 (HSP70) expression pattern between these breeds. The study was conducted over 45 days during summer (April-May) using 36 1-year-old female goats by randomly allocating them into six groups with six animals in each group: Osmanabadi control (Osmanabadi CON), Osmanabadi heat stress (Osmanabadi HS), Malabari control (Malabari CON), Malabari heat stress (Malabari HS), Salem Black control (Salem Black CON), and Salem Black heat stress (Salem Black HS). The Osmanabadi CON, Malabari CON, and Salem Black CON animals were housed in a shed while the Osmanabadi HS, Malabari HS, and Salem Black HS groups were subjected to heat stress by exposing them to outside environment between 1000 and 1600 h during the experimental period. All 36 animals were provided with ad libitum feed and water. The data generated were analyzed by general linear model (GLM) repeated measurement analysis of variance. Results indicated that the drinking frequency (DF) was higher (p < 0.01) in heat stress groups (12.58, 12.25, and 10.75 times for the Osmanabadi HS, Malabari HS, and Salem Black HS, respectively) as compared to their respective control groups (5.67, 6.25, 5.58 times for the Osmanabadi CON, Malabari CON, and Salem Black CON, respectively). Water intake (WI) also showed similar trend to DF. The urinating frequency also (UF) differed between breeds with lower value (p < 0.05) recorded in the Salem Black HS (1.5 times) compared to the Malabari HS (2.92 times). The highest (p < 0.05) rumination time (RuT) was recorded in the Malabari HS (48.00 min) than both the Osmanabadi HS (20.91 min) and Salem Black HS (23.67 min). The heat stress increased (p < 0.05) all physiological variables at 1400 h. The findings of this study suggest RR, RT, and PBMC HSP70 are reliable biological markers for evaluating thermo-tolerance capacity of indigenous goat breeds.

Adaptation strategies of yak to seasonally driven environmental temperatures in its natural habitat

The gradual increase of ambient temperature (TA) at high altitude can cause heat stress as an effect of climate change and may shift the traditional habitat of yak to further higher altitude. Therefore, an attempt has been made in this study to evaluate the thermo-adaptability of yaks to different seasons at high altitude. The adaptive capabilities of yaks were assessed based on different heat tolerance tests in relation to changes in rectal temperature (RT; °F), respiration rate (RR; breaths/min), pulse rate (PR; beats/min), and plasma heat shock protein (HSP) profile. The experiment was conducted in 24 yaks, divided into three groups based on age as calf (n = 8), adult (n = 8), and lactating cow (n = 8). Thermal adaptability was determined by temperature humidity index (THI), dairy search index (DSI), and Benezra's thermal comfort index (BTCI) along with HSP70 profile. The THI was higher (P < 0.01) in summer than winter which increased from lowest (40.87) to highest (61.03) in summer by 20 points, where yaks were under heat load beyond THI 52. The RT (100.09 ± 0.18 °F), RR (21.76 ± 0.18), and PR (59.78 ± 0.32) increased by 23-35%, and this was correlated to the higher values of DSI exceeding 1 in calves (1.35 ± 0.03), lactating cows (1.29 ± 0.04), and adults (1.23 ± 0.32) during summer in comparison to winter (0.98 ± 0.02). The BTCI also showed values greater (P < 0.01) than 2 in calves (3.47 ± 0.27), lactating cows (3.23 ± 0.28), and adults (2.98 ± 0.29) which reflected 49-75% increase in rectal temperature and respiration rate during summer. Further, heat stress was substantiated by threefold higher (P < 0.01) level of plasma HSP70 in calves (189.61 ± 3.90 pg/ml) followed by lactating cows (168.62 ± 3.03 pg/ml) and adults (155.33 ± 2.30 pg/ml) against the winter average of 87.92 ± 3.19 pg/ml. Present results revealed that yaks were experiencing heat stress in summer at an altitude of 3000 m above sea level and calves were more prone to heat stress followed by lactating cows and adults.

Comparative assessment of growth performance of three different indigenous goat breeds exposed to summer heat stress

A study was conducted to assess comparatively the growth performance of three different indigenous goat breeds during exposure to summer heat stress. The primary objective of the study was to observe the heat stress impact on the growth performance based on the body weight changes, allometric measurements, growth hormone (GH) concentration and peripheral blood mononuclear cell (PBMC) Insulin-like growth factor-1 (IGF-1) mRNA expression pattern during the summer season in comparison with the local breed (Osmanabadi). Thirty-six ten-month- to one-year-old female goats of Osmanabadi, Malabari and Salem Black breeds were randomly divided into six groups, OC (n = 6; Osmanabadi control), OHS (n = 6; Osmanabadi heat stress), MC (n = 6; Malabari control), MHS (n = 6; Malabari heat stress), SBC (n = 6; Salem Black control) and SBHS (n = 6; Salem Black heat stress). Body weight was recorded at weekly intervals, whereas other growth and allometric measurements and blood collection were carried out at fortnightly intervals. Breed factor significantly (p < .05) influenced only few growth variables such as body weight, body mass index (BMI) and body condition score (BCS). However, heat stress treatment significantly (p < .05) reduced all growth parameters expect BMI. Further, the heat stress significantly (p < .01) increased plasma GH concentration in goats with significantly higher (p < .05) concentration recorded in OHS. Among the stress groups, the lower (p < .05) PBMC IGF-1 mRNA expression was recorded in OHS, while the higher (p < .05) expression was observed in SBHS indicating the extreme adaptive capability of Salem Black breed. Thus, the results indicated that the Salem Black breed performed much better compared to both Osmanabadi and Malabari breeds indicating the superior ability of this breed to adapt to heat stress challenges. The results also indicated that plasma GH and IGF-1 gene may act as ideal biomarkers for assessing the heat stress impact on growth performance in indigenous goats.

Sitagliptin 100 mg vs glimepiride 1-3 mg as an add-on to insulin and metformin in type 2 diabetes (SWIM)

OBJECTIVE

To compare the effect of sitagliptin (100 mg) vs glimepiride (1-3 mg) as add-on therapy in Indian type 2 diabetes (T2DM) patients on treatment with insulin and metformin (SWIM study).

RESEARCH DESIGN AND METHODS

This 24-week, controlled, open-label study randomized T2DM patients (n = 440) receiving a stable dose of metformin and insulin combination therapy to sitagliptin (100 mg) or glimepiride (1-3 mg) as add-on therapy. Baseline HbA1c was ≥7.3% and ≤8.5%. After a 6-week titration period for glimepiride (dose titrated every 2 weeks by 1 mg up to a maximum of 3 mg daily), patients were continued for 18 weeks on their respective tolerable doses of glimepiride (ranging from 1 mg to 3 mg) or sitagliptin (100 mg) along with metformin and insulin.

RESULTS

Greater reductions in HbA1c and TDD of insulin were achieved with sitagliptin compared to glimepiride. HbA1c targets and reductions in TDD were achieved by more patients on sitagliptin than on glimepiride. Reductions in both body weight and BMI were also noted among patients on sitagliptin when compared to those on glimepiride, and more hypoglycemic events occurred with glimepiride treatment than with sitagliptin.

CONCLUSIONS

Sitagliptin (100 mg), when compared to glimepiride (1-3 mg), bestowed beneficial effects to T2DM patients in terms of achieving greater glycemic control and also brought significant reductions in total daily dose of insulin required, bodyweight, BMI and hypoglycemic events. Overall, the results suggest that sitagliptin (100 mg) is a superior agent over glimepiride (1-3 mg) as an add-on to insulin-metformin therapy among Asian Indians with T2DM.