Glycaemic control and long-term outcomes following transition from modified intensive insulin therapy to conventional glycaemic control

This retrospective observational cohort study compared glycaemic control and long-term outcomes following transition from a modified intensive insulin therapy (mIIT) regimen to conventional glycaemic control (CGC) in adult patients admitted to a tertiary adult general intensive care unit, during two 24-month periods, before and after the publication of the Normoglycemia in Intensive Care Evaluation and Surviving Using Glucose Algorithm Regulation (NICE-SUGAR) trial. The before NICE-SUGAR cohort received mIIT (target glycaemic ranges 4.4 to 7.0 mmol/l), while the after NICE-SUGAR cohort received CGC (target glycaemic range 7.1 to 9.0 mmol/l). A total of 5202 patients were included in the study. With transition from mIIT to CGC, the mean time-weighted glucose increased from 6.94 mmol/l to 8.2 mmol/l (P <0.0001). A similar increase was observed in other glycaemic indices (mean, highest and lowest glucose values, P <0.0001 for all). The adjusted 90-day odds ratio for mortality decreased by 47% with transition from mIIT to CGC (odds ratio 1.47 (95% confidence interval, 1.22 to 1.78) (P <0.0001). The rate of severe and moderate hypoglycaemia also decreased from 1.2 to 0.4% (P=0.004) and from 23.3 to 5.9% (P <0.0001), respectively. mIIT was associated with an increased risk of moderate and severe hypoglycaemia compared to CGC (odds ratio 3.1 (1.51 to 6.39) (P=0.002), 6.29 (5.1 to 7.75) (P <0.0001)). Changes in recommended glycaemic control were translated into practice, with increased glycaemic indices and decreased rates of severe and moderate hypoglycaemia after the introduction of CGC. The associated decrease in 90-day mortality suggests mIIT was not superior to CGC, despite a lower hypoglycaemia rate than in previous IIT trials. Our findings support the continued use of CGC.

IgE antibody response against Aspergillus umbrosus in farmer's lung disease

IgG and IgA antibodies against fungus Aspergillus umbrosus have been found in the sera of patients with farmer's lung (FL) disease and healthy exposed farmers in Finland. To determine the IgE response to antigens of A. umbrosus and Candida albicans, sera from 20 patients with FL, 20 healthy farmers and 20 nonfarming controls were tested by nitrocellulose radioallergosorbent test (RAST). The values of RAST indices were low in each group and the only statistically significant difference was found between the groups of FL patients and nonfarming controls against A. umbrosus polysaccharide antigen. Individual IgE responses to polysaccharide antigens of A. umbrosus and C. albicans correlated among FL patients, however, no cross-reacting IgE antibodies could be shown. To conclude, the IgE antibody levels of A. umbrosus polysaccharide and crude antigens were low in FL patients, healthy exposed farmers and nonfarming controls. Neither polysaccharide nor crude antigen-specific IgE antibodies of A. umbrosus have any diagnostic value in FL disease.

Identification of the reactive subunits of Aspergillus umbrosus involved in the antigenic response in farmer's lung

BACKGROUND

Farmer's lung (FL) is the most common form of extrinsic allergic alveolitis and the fungus Aspergillus umbrosus has frequently been associated with FL among Finnish farmers. IgG and IgA class antibodies against Aspergillus umbrosus are found in the serum of FL patients and healthy exposed farmers. So far the immunologically reactive subunits of Aspergillus umbrosus are unknown.

OBJECTIVES

The purpose of the study was to identify and localize the reactive subunits of Aspergillus umbrosus that are involved in the antigenic response in FL.

METHODS

The distribution of the primary antibody on the outer wall layers of 4- and 11 day-old fungi Aspergillus umbrosus was studied by pre-embedding immunolabelling with fluorescein isothiocyanate (FITC)- and gold-conjugated antibodies. The surface carbohydrates of the outer wall layers were studied using FITC-conjugated lectins.

RESULTS

FITC-conjugated antibodies from FL patient sera reacted with spores (conidia), phialides and hyphae, whereas the fruiting body, cleistothecia, remained unstainable. Immunofluorescence labelling was confirmed by immunolabelling electron microscopy, and gold-conjugated IgG antibodies were found on the outer cell walls of spinulose conidia, and in a less degree on the outer cell walls of hyphae and phialides. Only single gold particles were found scattered on the surfaces of cleistothecia. The surface carbohydrates of Aspergillus umbrosus conidia, vesicles, phialides and hyphae had a high affinity to GlcNAc beta 1- and Man alpha 1-/Glc alpha 1-specific lectins and only GlcNAc beta 1-specific lectins also reacted with the outer cell walls of cleistothecia. Blocking of the antigenic sites of Aspergillus umbrosus by preincubating antigen-coated enzyme linked immunosorbent assay (ELISA) plates with lectins caused some inhibition, indicating that sites with the highest affinity for lectins were not always antigenic sites.

CONCLUSION

Gold-and FITC -conjugated antibodies were distributed mostly on the outer wall layers of conidia, hyphae and phialides of Aspergillus umbrosus and GlcNAc beta 1-linked lectins had the strongest affinity to the outer wall layers.

Avidity of Aspergillus umbrosus IgG antibodies in farmer's lung disease

Farmer's lung disease (FL), the commonest form of allergic alveolitis caused by repeated inhalation of mouldy hay, is associated with exposure to the fungus Aspergillus umbrosus among Finnish farmers. The antigen-binding avidity of A. umbrosus-specific IgG antibodies was measured in 12 FL patients in acute phases of initial and recurrent attacks and during 1 year follow up as well as in 12 healthy farmers and five healthy urban controls. The farmers' groups were further divided into two subgroups: subjects with short exposure (< 7 years) and subjects with long exposure (> 25 years). During the first acute phase FL patients with long exposure exhibited a high avidity of A. umbrosus-specific IgG antibodies that remained high during the 1 year follow up, although the A. umbrosus-specific IgG antibody titre decreased. A re-exposure to mouldy hay leading to a recurrence further enhanced the maturation of the antibody avidity, so that an even higher A. umbrosus-specific IgG avidity with a less significant increase of antibody titre occurred than during the first acute attack. Notably higher IgG antibody avidity was observed in FL patients with long exposure than in healthy farmers or in healthy controls.

IgG and IgA subclass antibodies against Aspergillus umbrosus in farmer's lung disease

Fifty patients with farmer's lung disease (FL), 20 asymptomatic exposed farmers, and 18 healthy controls were investigated for total IgG and total IgA, as well as subclass antibody levels against Aspergillus umbrosus, the most common fungus to which FL patients in Finland have been exposed. Enzyme-linked immunosorbent assay (ELISA) revealed significantly elevated levels of specific total IgG and IgA antibodies in the sera of patients during the acute phase of the disease. Both IgG1 and IgG2 subclass antibodies and both IgA1 and IgA2 subclass antibodies were significantly associated with the disease. The antibody levels decreased during the first 3 months, when mould exposure was avoided and when an oral 6-week steroid treatment was administered. During the next 12 month follow-up, the mean antibody levels continued to decrease, even though re-exposure might have occurred. The results (with sensitivity 94% and specificity 95%) imply that in addition to the measurement of A. umbrosus-specific IgG, determination of both A. umbrosus-specific IgG1 and IgA might also be useful in the serodiagnosis of acute stage of FL.

Characterization of Aspergillus umbrosus carbohydrate antigens by biotinylated lectins and IgG response to mannan/mannoprotein antigens in patients with farmer's lung

Twenty-one different biotinylated lectins were used to recognize the carbohydrates of Aspergillus umbrosus, one of the most common microbes that patients with farmer's lung in Finland are exposed to. The glycoprotein fraction of A. umbrosus was bound especially well by Concanavalin A and consisted mainly of carbohydrates mannose and glucose. The carbohydrate fraction of A. umbrosus antigens were isolated from the crude extract of A. umbrosus with Con A-Sepharose affinity chromatography. Serum IgG antibodies to A. umbrosus mannoprotein fraction were determined in 57 patients with farmer's lung, 10 asymptomatic exposed farmers and 10 healthy controls by enzyme linked immunosorbent assay. Candida albicans and Saccharomyces cerevisiae mannan were used as controls. Patients had high levels, whereas asymptomatic exposed farmers showed moderate, and health controls low levels, of IgG antibodies to the A. umbrosus mannan/mannoprotein fraction. There were no significant differences in the mean antibody levels between the patients and controls against C. albicans or S. cerevisiae mannose fraction although in all groups more antibodies were detected against C. albicans than S. cerevisiae.