Meal replacement reduces insulin requirement, HbA1c and weight long-term in type 2 diabetes patients with >100 U insulin per day

BACKGROUND

Despite high insulin doses, good glycaemic control is often lacking in type 2 diabetes patients and new therapeutic options are needed.

METHODS

In a proof of principle study, an energy-restricted, protein-rich meal replacement (PRMR) was examined as a means of reducing insulin requirement, HbA1C and body weight. Obese type 2 diabetes patients (n = 22) with >100 U insulin per day replaced, in week 1, the three main meals with 50 g of PRMR (Almased-Vitalkost) each (= 4903 kJ day(-1) ). In weeks 2-4, breakfast and dinner were replaced, and, in weeks 5-12, only dinner was replaced. Clinical parameters were determined at baseline, and after 4, 8 and 12 weeks, as well as after 1.5 years of follow-up. The Wilcoxon signed-rank test was used for the intention-to-treat analysis and the Mann-Whitney U-test for subgroup analyses.

RESULTS

The 12-week-programme was completed by 15 participants (68%). After 1 week, the mean insulin dose was reduced from 147 (75) U to 91 (55) U day(-1) (P = 0.0001), and to 65 (32) U (P < 0.0001) after 12 weeks of study. Over a period of 12 weeks, HbA1c decreased from 8.8% (1.4%) to 8.1% (1.6%) (P = 0.048) and weight decreased from 118.0 (19.7) kg to 107.4 (19.2) kg (P < 0.0001). Moreover, body mass index, waist and hip circumference, fasting blood glucose, triglycerides and high-density lipoprotein cholesterol improved significantly. After 1.5 years, insulin requirement and weight remained significantly lower than baseline. Participants who continued PRMR further reduced their HbA1c, weight and insulin dose. Two patients were able to stop insulin therapy altogether.

CONCLUSIONS

Energy-restricted PRMR was effective in reducing insulin requirement of type 2 diabetes patients with intensified insulin therapy accompanied by a reduction of HbA1c, weight and other cardiometabolic risk factors. With the continuous use of PRMR, glycaemic control might be improved in the long term.

Intrathecal EBV antibodies are part of the polyspecific immune response in multiple sclerosis

OBJECTIVE

One mechanism underlying the link between multiple sclerosis (MS) and Epstein-Barr virus (EBV) might be a direct CNS infection. Viral CNS infections cause elevated antibody indices (AIs). Elevated EBV AIs were found in MS; however, patients with MS frequently show a polyspecific intrathecal immune response with elevated antiviral AIs. To discriminate whether elevated EBV AIs indicate a virus-driven or a polyspecific intrathecal immune response, we determined the intrathecal fraction of anti-EBV antibodies.

METHODS

The fraction of intrathecally synthesized EBV-specific immunoglobulin G (IgG) of the total intrathecally synthesized IgG (F(S) anti-EBV) was determined in 24 patients with a clinically isolated syndrome (CIS) or MS and 3 patients with cerebral posttransplantation lymphoproliferative disorder (PTLD), all of whom had elevated EBV AIs. F(S) anti-measles and AIs for measles, rubella, varicella zoster, and herpes simplex virus were measured as well. The prevalence of an elevated EBV AI was analyzed in another 36 patients with CIS.

RESULTS

Median F(S) anti-EBV in patients with CIS/MS was low (0.65%) and did not differ from F(S) anti-measles (0.9%). Median F(S) anti-EBV was about 40-fold higher in patients with cerebral PTLD than in patients with CIS/MS. All 24 patients with CIS/MS with an elevated EBV AI had at least one further elevated antiviral AI. Only 2 of 36 (5.6%) patients with CIS showed an intrathecal synthesis of anti-EBV antibodies.

CONCLUSIONS

Intrathecally produced anti-EBV antibodies are part of the polyspecific intrathecal immune response in CIS/MS and only rarely detectable in patients with CIS, both arguing against a direct CNS infection with EBV in patients with CIS/MS.

All reovirus subtypes show oncolytic potential in primary cells of human high-grade glioma

Reoviridae are non-human pathogenic viruses. The family of reoviridae consists of 4 different subtypes. Many studies have proven that the Dearing subtype 3 has oncolytic potential. This potential is related to the RAS protein expression in tumour cells. The aim of this study, was to investigate whether all reovirus subtypes have oncolytic potential and whether there are differences in their efficacy, in particular for high-grade glioma. To evaluate the oncolytic potential, we performed an in vitro head-to-head study for all reovirus subtypes in 5 primary cell cultures of high-grade gliomas. The oncolytic activity was determined using end-point titration with observation of the cytopathogenic effect. For measurement of RAS activity, we performed an immunofluorescent detection stain on all cell cultures. For quantification of the virus, an RT-PCR measurement for all subtypes was performed. All reovirus subtypes showed oncolytic activity in the observed glioma biopsies. These observations correlated with RAS overexpression in the observed cells. All glioma biopsies overexpressed the RAS protein. The quantitative oncolytic potential differed in relation to the single observed cell culture and in relation to the chosen reovirus subtype. To our knowledge, this is the first study showing oncolytic activity for all reovirus subtypes. We show the relationship and correlation between RAS protein overexpression and vulnerability of cells to reovirus. Efficacy of the different subtypes is interindividually different and cannot be forecast.

Cardiogenic shock in a neonate with enterovirus myocarditis

BACKGROUND

Left ventricular compromise in the neonate may be caused by birth asphyxia, metabolic disease, congenital heart disease, and systemic bacterial or viral infections. In rare cases, enterovirus infection may cause severe disease including cardiac, cerebral, hepatic and multi organ failure.

PATIENTS AND METHODS

Case report.

RESULTS

A 3-week-old neonate was admitted to our NICU in cardiogenic shock and severe lactic acidosis (ph: 6.9; serum lactate: 15 mmol/l, base excess: -19.8 mmol/l; pCO (2): 54.9 mm Hg). Serum troponin T was within the normal range; serum total creatinin phosphokinase was 57 U/l, CK-MB 110 U/l, LDH 762 U/l; pro-BNP: 64391 pg/ml was elevated. On echocardiography left ventricular function was depressed with a shortening fraction of 16%. The neonate was started on inotropes. There was gradual improvement over the following two weeks with normalisation of left ventricular output. PCR examination was positive for enterovirus. Other causes for left ventricular compromise (congenital heart disease, inborn errors of metabolism, etc.) were ruled out by adequate means.

CONCLUSIONS

Enterovirus infection as a cause for myocarditis and cardiogenic shock should be taken into the differential diagnosis in neonates.

Reduced serum 25-hydroxyvitamin D levels in stage IV melanoma patients

BACKGROUND

Reduced serum 25-hydroxyvitamin D3 (25(OH)D) levels are associated with an increased incidence and an unfavorable outcome of various types of cancer. However, the influence of serum 25(OH)D on the incidence and outcome of patients with malignant melanoma is unknown.

PATIENTS AND METHODS

The association between serum 25(OH)D levels and clinical and histopathological data among 205 patients with malignant melanoma was examined. Additionally, 141 healthy controls were investigated. All the blood samples were taken between October and April to minimize seasonal variations; basal serum 25(OH)D levels were analyzed using the LIAISON 25-OH Vitamin D-Assay (DiaSorin, Dietzenbach, Germany). The study started in 1997. The patients were observed until death or March 2007, whichever came first.

RESULTS

Serum 25(OH)D levels were significantly reduced in stage IV melanoma patients as compared to stage I melanoma patients (p=0.006). A trend toward a greater tumor thickness of the primary cutaneous melanomas was seen in the patients with low (<10 ng/ml) serum 25(OH)D levels (median: 2.55 mm) as compared to those with 25(OH)D serum levels >20 ng/ml (median: 1.5 mm), although this difference was not statistically significant (p=0.078). The patients with low 25(OH)D serum levels (<10 ng/ml) had earlier distant metastatic disease (median: 24.37 months) as compared to those with 25(OH)D serum levels >20 ng/ml (median: 29.47 months), although this difference was also not statistically significant (p=0.641).

CONCLUSION

Among the patients with malignant melanoma, significantly reduced serum 25(OH)D levels were found in the stage IV patients as compared to stage I patients, and those with low 25(OH)D serum levels (<10 ng/ml) may develop earlier distant metastatic disease compared to those with higher 25(OH)D serum levels (>20 ng/ml). Further study of the vitamin D pathway and its influence on pathogenesis and progression of malignant melanoma is warranted.

[Parvovirus B-19 infections in pregnant women in day care facilities: health economic analysis of prohibition to employ seronegative women]

German protective legislation during pregnancy and maternity prohibit employing pregnant women if occupational activities endanger the health of either the mother-to-be or the fetus. This applies for parvovirus B19 seronegative women caring for children <6 years. Here we present a cost-effectiveness analysis from the view of the society for the prohibition to employ B19-seronegative women in day care. Prohibition of employment starting at the first day of pregnancy may prevent 1.4 cases of fetal death (mortality) and 1.7 cases of hydrops fetalis (morbidity) per year resulting in costs of 30 million <euro> (22 million <euro>/live birth). The incidence of B19 infection, the elevated occupational risk and the fetal death rate were varied in sensitivity analyses. This resulted in 0.2-3.1 fetal deaths prevented per year and costs between 10 million <euro> and 150 million <euro> per live birth. Indeed, the protective effect is assumed to be even lower since 30% of fetal deaths occur after infection during the first 8 weeks of pregnancy. During that time prohibition of employment is often unrealistic since the majority of women are not aware of pregnancy. In conclusion a small number of fetal lives can be saved by prohibiting employment in contrast to the extremely high costs. The regulations for maternal protection should be revised.

Coxsackie virus B 4 encephalitis in a 7 year old boy

BACKGROUND

Enteroviruse belongs to the family of picornaviruses. They can be devided in 4 groups: polioviruses (Typ 1-3) enteric cythopathogenic human orphan (ECHO)- viruses, unclassified enteroviruses 68-71 and coxsackie viruses. Coxsackie virus type B can cause pharyngitis, myalgia, myocarditis and meningitis as well as severe neonatal infections.

CASE REPORT

We report a patient with coxsackie type B 4 encephalitis. A 7 year old boy had 2 episodes of mental dizziness and consciousness disturbance. Because of he presented a visus of 70 %, headaches and vomiting he was admitted to our hospital. In the cerebrospinal fluid a coxsackie virus type B 4 could be identified. With nonspecific therapy the boy recovered.

CONCLUSION

We concluded that coxsackie virus B 4 caused acute encephalitis with ophthalmological and mental symptoms and good prognosis. Coxsackie virus B 4 should be considered in patients with encephalitis.

Patients with extratemporal lobe epilepsy do not differ from healthy subjects with respect to subcortical volumes

BACKGROUND

Evidence from previous volumetric magnetic resonance studies has revealed that patients with chronic temporal lobe epilepsy show atrophy of distinct subcortical nuclei, predominantly ipsilateral to the focus side. We were interested to find out if there is also selective subcortical atrophy in patients suffering from long standing extratemporal lobe epilepsy.

METHODS

Thirty one patients in whom pre-surgical evaluation unambiguously localised an extratemporal focus were included in this study. Using high resolution magnetic resonance imaging, the volumes of the caudate nuclei, putamen, pallidum, and thalamus were measured bilaterally in both hemispheres and compared with measurements obtained in 15 healthy volunteers.

RESULTS

No significant difference in volumes was found between the two subject groups, or in any subgroup of extratemporal lobe epilepsy patients, nor was there any relation to clinical variables such as age of onset, overall seizure frequency, or disease duration. However, patients who had no or only rare generalised tonic-clonic seizures seemed to differ from the other patients and controls in that they had smaller putamen volumes bilaterally (p<0.001).

CONCLUSION

We concluded that extratemporal lobe epilepsy in general is not associated with diminished volumes in the studied subcortical structures, which contrasts with findings in temporal lobe epilepsy patients. Thus, both entities differ both cortically and subcortically. However, we found that small putamen volume was bilaterally associated with absent or rare generalised tonic-clonic seizures, implicating the putamen in the control of the most disabling seizure type, independent of the site of neocortical focus.

Levels of virus-specific CD4 T cells correlate with cytomegalovirus control and predict virus-induced disease after renal transplantation

BACKGROUND

Immunosuppressive treatment in transplant patients frequently causes infectious complications with cytomegalovirus (CMV). The extent of CMV replication can be followed by a number of diagnostic methods. There is, however, no simple diagnostic tool to assess the quality of the cellular antiviral immune response of an individual patient. This would be of particular importance for therapy decisions, as patients with detectable virus load do not necessarily develop CMV-related disease. Using a rapid whole blood assay, the frequencies of CMV-reactive CD4 and CD8 T cells were followed after renal transplantation to characterize their relative contribution in the containment of CMV infection.

METHODS

T cells from transplant patients ands healthy control persons were stimulated with CMV antigen in vitro. Based on specific cellular activation and induction of intracellular cytokines, the frequency of CMV-reactive CD4 and CD8 T cells was determined using flow cytometry. Viral load quantified using the "hybrid-capture" assay.

RESULTS

The absence of CMV complications in long-term transplant recipients is reflected by stable virus-specific T-cell frequencies, which do not differ from healthy CMV-positive controls. In contrast, during the first months after transplantation, clinical symptoms are preceded by a decrease in CMV-reactive CD4 T-cell frequencies and an increase in CMV load.

CONCLUSIONS

The individual immune response and CMV replication are critically balanced and can be characterized by assesing both viral load and antiviral T cells. Our experimental design allows the identification of patients with sufficient, insufficient, or absent T-cell activity and can serve as diagnostic tool to facilitate decisions on antiviral therapy.

Identification and characterization of MTR1, a novel gene with homology to melastatin (MLSN1) and the trp gene family located in the BWS-WT2 critical region on chromosome 11p15.5 and showing allele-specific expression

Alterations within human chromosomal region 11p15.5 are associated with the Beckwith-Wiedemann syndrome (BWS) and predisposition to a variety of neoplasias, including Wilms' tumors (WTs), rhabdoid tumors and rhabdomyosarcomas. To identify candidate genes for 11p15. 5-related diseases we compared human genomic sequence with expressed sequence tag and protein databases from different organisms to discover evolutionarily conserved sequences. Herein we describe the identification and characterization of a novel human transcript related to a putative Caenorhabditis elegans protein and the trp (transient receptor potential) gene. The highest homologies are observed with the human TRPC7 and with melastatin 1 ( MLSN1 ), whose transcript is downregulated in metastatic melanomas. Other genes related to and interacting with the trp family include the Grc gene, which codes for a growth factor-regulated channel protein, and PKD1/PKD2, involved in polycystic kidney disease. The novel gene presented here (named MTR1 for MLSN1 - and TRP -related gene 1) resides between TSSC4 and KvLQT1. MTR1 is expressed as a 4.5 kb transcript in a variety of fetal and adult tissues. The putative open reading frame is encoded in 24 exons, one of which is alternatively spliced leading to two possible proteins of 872 or 1165 amino acids with several predicted membrane-spanning domains in both versions. MTR1 transcripts are present in a large proportion of WTs and rhabdomyosarcomas. RT-PCR analysis of somatic cell hybrids harboring a single human chromosome 11 demonstrated exclusive expression of MTR1 in cell lines carrying a paternal chromosome 11, indicating allele-specific inactivation of the maternal copy by genomic imprinting.

The effects of CO2 and fixed acid on the O2-Hb affinity of rabbit and cat blood

The action of respiratory and metabolic acid-base disturbances on the O2-Hb affinity was studied in rabbits and cats. Blood samples of both species were exposed to in vitro pH-changes, which were either achieved by variation of PCO2 (2.8-8.3 kPa) at constant lactic acid concentration, or by addition of lactic acid (5-14 mmol X 1(-1) at constant PCO2. The PO2 at halfsaturation (P50) and the Hill's n were determined from O2-Hb dissociation curves (ODC) in a range between 20 and 80% SO2. Under standard conditions (T = 311 K, PCO2 = 5.33 kPa, pH = 7.4), the average P50 value was 4.66 +/- 0.05 kPa in rabbits, that is slightly higher than reported by others, and 5.17 +/- 0.03 kPa in cats. The average values of Hill's n were 2.91 +/- 0.02 and 2.95 +/- 0.03 for rabbits and cats, respectively. When plasma pH was varied by CO2, the resulting classical CO2 Bohr factor phi CO2 = delta lgP50/delta pH50 was distinctly higher in cats (-0.560 +/- 0.006, n = 25) than in rabbits (-0.504 +/- 0.014, n = 22), although in the latter species being even higher than reported elsewhere. Concomitant metabolic acidosis did not significantly affect phi CO2, but shifted the P50 at a given plasma pH to lower values. Substitution of lactic acid with equimolar amounts of sodium lactate left both phi CO2 and P50 unchanged.(ABSTRACT TRUNCATED AT 250 WORDS)

On the seemingly diminished CO2-Bohr effect in hypoxic chemodenervated rabbits

In hypoxic rabbits, different levels of Pco2 before and after carotid chemodenervation were applied in order to get information about the acid-base status and the position of the O2-Hb dissociation curve (ODC). A CO2-induced change in pH caused a smaller change in the half-saturation pressure (P50) than was to be expected from the CO2-Bohr effect alone. Considering both, the numerically different CO2- and fixed acid-Bohr factors as well as the corresponding respiratory or metabolic pH changes, a method is presented to calculate the position of the ODC with high accuracy. From these considerations it can be derived that the seemingly diminished CO2-Bohr effect in hypoxic rabbits in vivo, especially after chemodenervation , is due more or less to accumulation of lactid acid. This leads to an increasing error if only the CO2-Bohr factor and the actual pH change are taken into account.

Structure of flavin adducts with acetylenic substrates. Chemistry of monoamine oxidase and lactate oxidase inhibition

The photoreaction of flavoquinones (lumiflavin, riboflavin, FMN etc. and their 3-alkylated derivatives) with propargylamine-type acetylenic substrates, R4 -Calpha identical to Cbeta -CgammaHR3 -NR2R1, yields a mixture of two adducts,which result from covalent Calpha fixation of the Cgamma-deprotonated substrate to either position C(4a) or N(5) in the flavin nucleus. The N(5) adduct is a dihydroflavin-5-trimethine-cyanine with very intense (xi greater than 20000 M-1 cm-1) absorption maxima in the region 380-450 nm depending on the R1,R2. This absorption allows recognition of minute amounts of this species of flavocyanine even in complex mixtures. Flavocyanines can be reconverted to starting flavin by base. It spectral properties are identical with those obtained for the pargyline-flavin inhibitor complex from bovine kidney or pig liver monoamine oxidase.

4a,5-Cycloaddiction reactions of acetylenic compounds at the flavoquinone nucleus as mechanisms of flavoprotein inhibitions

4a,5-Cycloaddition at the flavoquinone, Mechanism of flavoprotein inhibitions

Photochemically, covalent cycloaddition products of flavoquinone and acetylenic enzyme inhibitors have been prepared and elucidated, which appear analogous to flavoprotein-inhibitor complexes (monoamine and lactate oxidase). The additions occur with inhibitors of general type HC≡C-CH< at the C (4a) = N (5) azomethine grouping of oxidized flavin. The spectral properties of adducts and their chemical reactivity is described.