Bihormonal fully closed-loop system for the treatment of type 1 diabetes: a real-world multicentre, prospective, single-arm trial in the Netherlands.

BACKGROUND: Management of insulin administration for intake of carbohydrates and physical activity can be burdensome for people with type 1 diabetes on hybrid closed-loop systems. Bihormonal fully closed-loop (FCL) systems could help reduce this burden. In this trial, we assessed the long-term performance and safety of a bihormonal FCL system. METHODS: The FCL system (Inreda AP; Inreda Diabetic, Goor, Netherlands) that uses two hormones (insulin and glucagon) was assessed in a 1 year, multicentre, prospective, single-arm intervention trial in adults with type 1 diabetes. Participants were recruited in eight outpatient clinics in the Netherlands. We included adults with type 1 diabetes aged 18-75 years who had been using flash glucose monitoring or continuous glucose monitors for at least 3 months. Study visits were integrated into standard care, usually every three months, to evaluate glycaemic control, adverse events, and person-reported outcomes. The primary endpoint was time in range (TIR; glucose concentration 3·9-10·0 mmol/L) after 1 year. The study is registered in the Dutch Trial Register, NL9578. FINDINGS: Between June 1, 2021, and March 2, 2022, we screened 90 individuals and enrolled 82 participants; 78 were included in the analyses. 79 started the intervention and 71 were included in the 12 month analysis. Mean age was 47.7 (SD 12·4) years and 38 (49%) were female participants. The mean preintervention TIR of participants was 55·5% (SD 17·2). After 1 year of FCL treatment, mean TIR was 80·3% (SD 5·4) and median time below range was 1·36% (IQR 0·80-2·11). Questionnaire scores improved on Problem Areas in Diabetes (PAID) from 30·0 (IQR 18·8-41·3) preintervention to 10·0 (IQR 3·8-21·3; p<0·0001) at 12 months and on World Health Organization-Five Well-Being Index (WHO-5) from 60·0 (IQR 44·0-72·0) preintervention to 76·0 (IQR 60·0-80·0; p<0·0001) at 12 months. Five serious adverse events were reported (one cerebellar stroke, two severe hypoglycaemic, and two hyperglycaemic events). INTERPRETATION: Real-world data obtained in this trial demonstrate that use of the bihormonal FCL system was associated with good glycaemic control in patients who completed 1 year of treatment, and could help relieve these individuals with type 1 diabetes from making treatment decisions and the burden of carbohydrate counting. FUNDING: Inreda Diabetic.

Virtual Acute Psychiatric Ward: Evaluation of Outcomes and Cost Savings.

OBJECTIVE: The COVID-19 pandemic motivated rapid expansion of virtual care. In Winnipeg, Canada, the authors launched a virtual psychiatric acute care ward (vWARD) to divert patients from hospitalization through daily remote treatment by a psychiatry team using telephone or videoconferencing. This study examined vWARD patient characteristics, predictors of transfer to a hospital, use of acute care postdischarge, and costs of the vWARD compared with in-person hospitalization. METHODS: Data for all vWARD admissions from March 23, 2020, to April 30, 2021, were retrieved from program documents and electronic records. Emergency department visits and hospitalizations in the 6 months before admission and the 30 days after discharge were documented. Logistic regression identified factors associated with transfer to a hospital. Thirty-day acute care use after discharge was modeled with Kaplan-Meier curves. A break-even cost analysis was generated with data for usual hospital-based care. RESULTS: The 132 vWARD admissions represented a diverse demographic and clinical population. Overall, 57% involved suicidal behavior, and 29% involved psychosis or mania. Seventeen admissions (13%) were transferred to a hospital. Only presence of psychosis or mania significantly predicted transfer (OR=34.2, 95% CI=3.3-354.6). Eight individuals were hospitalized in the 30 days postdischarge (cumulative survival=0.93). vWARD costs were lower than usual care across several scenarios. CONCLUSIONS: A virtual ward is a feasible, effective, and potentially cost-saving intervention to manage acute psychiatric crises in the community and avoid hospitalization. It has benefits for both the health system and the individual who prefers to receive care at home.

[A woman with oedema of the lower legs]. / Een vrouw met oedeem van de onderbenen.

We present a 46-year-old female with hyperthyroidism, orbitopathy and dermopathy who we diagnosed with Grave's disease. Myxoedema is a rare extrathyroidal symptom and is associated with orbitopathy. TSH-receptor expressing fibroblasts lead to by accumulation of subcutaneous glycosaminoglycans, causing the oedema. Often it is self-limiting, but corticosteroid therapy may be required.

Performance and safety of an integrated bihormonal artificial pancreas for fully automated glucose control at home.

AIMS: To assess the performance and safety of an integrated bihormonal artificial pancreas system consisting of one wearable device and two wireless glucose sensor transmitters during short-term daily use at home. METHODS: Adult patients with type 1 diabetes using an insulin pump were invited to enrol in this randomized crossover study. Treatment with the artificial pancreas started with a day and night in the clinical research centre, followed by 3 days at home. The control period consisted of 4 days of insulin pump therapy at home with blinded continuous glucose monitoring for data collection. Days 2-4 were predefined as the analysis period, with median glucose as the primary outcome. RESULTS: A total of 10 patients completed the study. The median [interquartile range (IQR)] glucose level was similar for the two treatments [7.3 (7.0-7.6) mmol/l for the artificial pancreas vs. 7.7 (7.0-9.0) mmol/l for the control; p = 0.123]. The median (IQR) percentage of time spent in euglycaemia (3.9-10 mmol/l) was longer during use of the artificial pancreas [84.7 (82.2-87.8)% for the artificial pancreas vs. 68.5 (57.9-83.6)% for the control; p = 0.007]. Time in hypoglycaemia was 1.3 (0.2-3.2)% for the artificial pancreas and 2.4 (0.4-10.3)% for the control treatment (p = 0.139). Separate analysis of daytime and night-time showed that the improvements were mainly achieved during the night. CONCLUSIONS: The results of this pilot study suggest that our integrated artificial pancreas provides better glucose control than insulin pump therapy in patients with type 1 diabetes at home and that the treatment is safe.

Multiple Orientia tsutsugamushi ankyrin repeat proteins interact with SCF1 ubiquitin ligase complex and eukaryotic elongation factor 1 α.

BACKGROUND: Orientia tsutsugamushi, the causative agent of scrub typhus, is an obligate intracellular bacterium. Previously, a large number of genes that encode proteins containing eukaryotic protein-protein interaction motifs such as ankyrin-repeat (Ank) domains were identified in the O. tsutsugamushi genome. However, little is known about the Ank protein function in O. tsutsugamushi. METHODOLOGY/PRINCIPAL FINDINGS: To characterize the function of Ank proteins, we investigated a group of Ank proteins containing an F-box-like domain in the C-terminus in addition to the Ank domains. All nine selected ank genes were expressed at the transcriptional level in host cells infected with O. tsutsugamushi, and specific antibody responses against three Ank proteins were detected in the serum from human patients, indicating an active expression of the bacterial Ank proteins post infection. When ectopically expressed in HeLa cells, the Ank proteins of O. tsutsugamushi were consistently found in the nucleus and/or cytoplasm. In GST pull-down assays, multiple Ank proteins specifically interacted with Cullin1 and Skp1, core components of the SCF1 ubiquitin ligase complex, as well as the eukaryotic elongation factor 1 α (EF1α). Moreover, one Ank protein co-localized with the identified host targets and induced downregulation of EF1α potentially via enhanced ubiquitination. The downregulation of EF1α was observed consistently in diverse host cell types infected with O. tsutsugamushi. CONCLUSION/SIGNIFICANCE: These results suggest that conserved targeting and subsequent degradation of EF1α by multiple O. tsutsugamushi Ank proteins could be a novel bacterial strategy for replication and/or pathogenesis during mammalian host infection.

Groundwater geochemistry and microbial community structure in the aquifer transition from volcanic to alluvial areas.

Groundwaters may act as sinks or sources of organic and inorganic solutes, depending on the relative magnitude of biochemical mobilizing processes and groundwater-surface water exchanges. The objective of this study was to link the lithological and hydrogeological gradients to the aquatic microbial community structure in the transition from aquifer recharge (volcanic formations) to discharge areas (alluvial deposits). A field-scale analysis was performed along a water table aquifer in which volcanic products decreased in thickness and areal extension, while alluvial deposits became increasingly important. We measured the main groundwater physical parameters and the concentrations of major and trace elements. In addition, the microbial community structure was assessed by estimating the occurrence of total coliforms and Escherichia coli, the prokaryotic abundance, the cytometric and phylogenetic community composition. The overall biogeochemical asset differed along the aquifer flow path. The concentration of total and live prokaryotic cells significantly increased in alluvial waters, together with the percentages of Beta- and Delta-Proteobacteria. The microbial propagation over a theoretical groundwater travel time allowed for the identification of microbial groups shifting significantly in the transition between the two different hydrogeochemical facies. The microbial community structure was intimately associated with geochemical changes, thus it should be further considered in view of a better understanding of groundwater ecology and sustainable management strategies.

Phenotypic characterization of peripheral T cells and their dynamics in scrub typhus patients.

BACKGROUND: Scrub typhus, caused by Orientia tsutsugamushi infection, is one of the main causes of febrile illness in the Asia-Pacific region. Although cell-mediated immunity plays an important role in protection, little is known about the phenotypic changes and dynamics of leukocytes in scrub typhus patients. METHODOLOGY/PRINCIPAL FINDINGS: To reveal the underlying mechanisms of immunological pathogenesis, we extensively analyzed peripheral blood leukocytes, especially T cells, during acute and convalescent phases of infection in human patients and compared with healthy volunteers. We observed neutrophilia and CD4(+) T lymphopenia in the acute phase of infection, followed by proliferation of CD8(+) T cells during the convalescent phase. Massive T cell apoptosis was detected in the acute phase and preferential increase of CD8(+) T cells with activated phenotypes was observed in both acute and convalescent phases, which might be associated or correlated with elevated serum IL-7 and IL-15. Interestingly, peripheral Treg cells were significantly down-regulated throughout the disease course. CONCLUSIONS/SIGNIFICANCE: The remarkable decrease of CD4(+) T cells, including Treg cells, during the acute phase of infection may contribute to the loss of immunological memory that are often observed in vaccine studies and recurrent human infection.

IL-7Rαlow memory CD8+ T cells are significantly elevated in patients with systemic lupus erythematosus.

OBJECTIVE: Human effector memory (EM) CD8(+) T cells include IL-7Rα(high) and IL-7Rα(low) cells with distinct cellular characteristics, including the expression of cytotoxic molecules. Both NK cells and the NK cell-associated molecule 2B4 that is expressed on CD8(+) T cells promote cytotoxicity. Here we analysed the expression of 2B4 on IL-7Rα(high) and IL-7Rα(low) EM CD8(+) T cells and its contribution to cytotoxicity. We also analysed the frequency of IL-7Rα(high) and IL-7Rα(low) EM CD8(+) T cells in patients with SLE or lupus and in healthy individuals given the potential role of cytotoxic CD8(+) T cells in the pathogenesis of lupus. METHODS: We used flow cytometry to measure the expression of 2B4 on IL-7Rα(high) and IL-7Rα(low) EM CD8(+) T cells as well as the frequency of these cell populations in the peripheral blood of healthy individuals and patients with SLE. Also, 2B4-mediated cytotoxicity was quantitated in IL-7Rα(high) and IL-7Rα(low) EM CD8(+) T cells using target cells with CD48 antigen. RESULTS: We found that IL-7Rα(high) EM CD8(+) T cells had higher levels of 2B4 expression compared with IL-7Rα(low) EM CD8(+) T cells. Triggering 2B4 enhanced the cytotoxic function of IL-7Rα(low) EM CD8(+) T cells against target cells. We also noticed that patients with SLE had an increased frequency of IL-7Rα(low) EM CD8(+) T cells that correlated with disease manifestation. CONCLUSION: Our findings show that SLE patients have increased IL-7Rα(low) EM CD8(+) T cells, possibly contributing to tissue damage through 2B4-mediated cytotoxicity.

Characterization of effector memory CD8+ T cells in the synovial fluid of rheumatoid arthritis.

Little is known about the cellular characteristics of CD8(+) T cells in rheumatoid arthritis (RA). We addressed this by investigating whether the frequency of the CD8(+) T cell subsets and their phenotypic characteristics are altered in the peripheral blood and synovial fluid (SF) from patients with RA. In this study, CD8(+) T cells, mainly CD45RA(-) effector memory (EM) CD8(+) T cells, were increased significantly in the SF, but not in the peripheral blood from RA patients, compared with healthy controls. The synovial EM CD8(+) T cells were activated phenotypes with high levels of CD80, CD86, and PD-1, and had a proliferating signature in vivo upon Ki-67 staining, whereas the Fas-positive cells were prone to apoptosis. In addition, EM CD8(+) T cells in the SF were less cytotoxic, as they expressed less perforin and granzyme B. In particular, the proportions of synovial fluid mononuclear cells that were CCR4(+)CD8(+) T cells and IL-4-producing CD8(+) T cells (i.e., Tc2 cells) were significantly higher than those in peripheral blood mononuclear cells of patients with RA and healthy controls. In addition, the number of IL-10-producing CD8(+) suppressor T (Ts) cells increased significantly in the SF of RA patients. Especially, CD8(+) T cells were inversely correlated with disease activity. These findings strongly suggest that EM CD8(+) T cells in the SF are increased, likely because of inflammation, and they may be involved in modulating inflammation, thereby affecting the development and progression of RA.

Interactions of odorants with olfactory receptors and receptor neurons match the perceptual dynamics observed for woody and fruity odorant mixtures.

The present study aimed to create a direct bridge between observations on peripheral and central responses to odorant mixtures and their components. Three experiments were performed using mixtures of fruity (isoamyl acetate; ISO) and woody (whiskey lactone; WL) odorants known to contribute to some of the major notes in Burgundy red wine. These experiments consisted of (i) calcium imaging of human embryonic kidney cells (HEK293T) transfected with olfactory receptors (ORs); (ii) single-unit electrophysiological recordings from olfactory receptor neurons (ORNs) and analyses of electro-olfactogram (EOG) responses in the rat nose in vivo; and (iii) psychophysical measurements of the perceived intensity of the mixtures as rated by human subjects. The calcium imaging and electrophysiological results revealed that ISO and WL can act simultaneously on single ORs or ORNs and confirm that receptor responses to mixtures are not the result of a simple sum of the effects of the individual mixture compounds. The addition of WL to ISO principally suppressed the ORN activation induced by ISO alone and was found to enhance this activation in a subset of cases. In the human studies, the addition of high concentrations of WL to ISO decreased the perceived intensity of the ISO. In contrast, the addition of low concentrations of WL enhanced the perceived intensity of the fruity note (ISO) in this mixture, as it enhanced EOG responses in ORNs. Thus, both OR and ORN responses to ISO + WL mixtures faithfully reflected perceptual response changes, so the odour mixture information is set up after the peripheral stage of the olfactory system.

Involvement of Ca²+ signaling in intracellular invasion of non-phagocytic host cells by Orientia tsutsugamushi.

Calcium signaling has been implicated in various steps in bacterial pathogenesis. Here, we investigated the role of Ca(2+) signaling in intracellular invasion of non-phagocytic host cells infected with Orientia tsutsugamushi, the causative agent of scrub typhus. The bacteria induced a transient Ca(2+) increase in HeLa cells immediately after infection and the source of the mobilized Ca(2+) appears to be intracellular stores, not the extracellular milieu, as determined using extracellular (EGTA) or intracellular (BAPTA-AM) Ca(2+) chelators. O. tsutsugamushi rapidly induced activation of PLC-γ1, as indicated by tyrosine phosphorylation. PLC-γ1 activity increased within 1 min of infection and returned to the basal level by 5 min. Pretreatment of host cells with inhibitors of PLC-γ1 (U73122) or IP3R channel activity (2-APB) significantly blocked bacterial entry without affecting bacterial attachment. In addition, these chemical inhibitors were effective in suppressing not only the activation of ERK MAP kinase but also the expression of the chemokine MCP-1. Taken together, Ca(2+) signaling induced by O. tsutsugamushi may play a crucial role in bacterial pathogenesis including inflammatory reactions as well as intracellular invasion into non-phagocytic host cells.

[Hematoma of the rectus abdominis. experience of a primary care hospital]. / Hematoma del recto anterior del abdomen: experiencia en un hospital comarcal.

OBJECTIVE: To describe patients diagnosed with hematoma of the rectus abdominis (HRA) muscle. MATERIAL AND METHODS: A retrospective analysis of patients diagnosed with HRA over the past 8 years in our center. RESULTS: A total of 17 patients (9 women) with mean age of 73 years were included in the study. In 52% of the cases the HRA was the cause of hospitalization. Anticoagulant therapy was documented in 70%. More than half of patients treated with low molecular weight heparin had renal insufficiency. In the group receiving oral anticoagulants (OA), 86% had INR greater than 4. Paroxysmal cough appeared in 13. The most common presentation was abdominal pain and palpable mass. CT scan sensitivity was superior to that of the ultrasound. The most common location was the lower right. Treatment was conservative in all but one. Two patients died. Mean decrease in hemoglobin was 4.7 g/dl. Average stay was 19 days. CONCLUSIONS: In our center, HRA almost equally affects both genders and appears in older people with excessive anticoagulation and cough. The clinical presentation, increased diagnostic sensitivity of CT scan and predominance in the right abdominal involvement are similar to other series. Mortality and hospital stay are higher than described.

Hematoma del recto anterior del abdomen: experiencia en un hospital comarcal / Hematoma of the rectus abdominis. experience of a primary care hospital

Objetivo. Describir los pacientes diagnosticados de hematoma del recto anterior del abdomen (HRAA). Material y métodos. Análisis retrospectivo de pacientes diagnosticados de HRAA durante los últimos 8 años en nuestro centro. Resultados. Se incluyen 17 pacientes (9 mujeres) con edad media de 73 años. En el 52% de los casos el HRAA fue la causa del ingreso. El tratamiento anticoagulante se documentó en el 70%. Más de la mitad de pacientes tratados con heparinas de bajo peso molecular tenían insuficiencia renal. En el grupo de los que recibían AO, un 86% tenía un INR superior a 4. La tos paroxística aparecía en 13. La presentación más habitual fue dolor abdominal y masa palpable. La sensibilidad de la TAC fue superior a la ecografía. La localización más frecuente fue la inferior derecha. El tratamiento fue conservador en todos, excepto uno. Dos pacientes fallecieron. El descenso medio de la hemoglobina fue 4,7g/dl. La estancia media fue de 19 días. Conclusiones. En nuestro centro el HRAA afecta casi por igual a ambos sexos y aparece en personas de edad avanzada con exceso de tratamiento anticoagulante y tos. La presentación clínica, mayor sensibilidad diagnóstica de la TAC y predominancia en la afectación derecha del abdomen, es similar a otras series. La mortalidad y la estancia hospitalaria son superiores a lo descrito(AU)

Objective. To describe patients diagnosed with hematoma of the rectus abdominis (HRA) muscle. Material and methods. A retrospective analysis of patients diagnosed with HRA over the past 8 years in our center. Results. A total of 17 patients (9 women) with mean age of 73 years were included in the study. In 52% of the cases the HRA was the cause of hospitalization. Anticoagulant therapy was documented in 70%. More than half of patients treated with low molecular weight heparin had renal insufficiency. In the group receiving oral anticoagulants (OA), 86% had INR greater than 4. Paroxysmal cough appeared in 13. The most common presentation was abdominal pain and palpable mass. CT scan sensitivity was superior to that of the ultrasound. The most common location was the lower right. Treatment was conservative in all but one. Two patients died. Mean decrease in hemoglobin was 4.7g/dl. Average stay was 19 days. Conclusions. In our center, HRA almost equally affects both genders and appears in older people with excessive anticoagulation and cough. The clinical presentation, increased diagnostic sensitivity of CT scan and predominance in the right abdominal involvement are similar to other series. Mortality and hospital stay are higher than described(AU)

An exercise programme for patients with diabetic complications: a study on feasibility and preliminary effectiveness.

AIMS: To investigate the feasibility and preliminary effectiveness of an exercise programme for patients with diabetic complications. METHODS: In this pre-post design study, 22 patients from a diabetic foot outpatient clinic participated in a 12-week individualized exercise programme, consisting of aerobic and resistance exercise, with specific safety precautions. Feasibility was assessed on the basis of programme adherence, adverse events, achievement of the target training intensity and patient satisfaction. Preliminary effectiveness was evaluated with pre-post-changes in blood glucose regulation (HbA(1c) ), muscle strength (isometric peak torque) and perceived limitations in functioning (Patient Specific Function Scale with visual analogue scale). RESULTS: Twenty patients completed the exercise programme with a high mean attendance (85%). No training-related severe adverse events occurred. The target training intensity was achieved by 70% of the participants. Patient satisfaction was high. HbA(1c) decreased from 8.2% before to 7.8% after the programme (P=0.005), muscle strength increased from 136.4 to 150.4 Nm (P = 0.046) and perceived limitations in functioning decreased from 7.2 to 5.8 mm (P=0.003). CONCLUSIONS: The prescribed exercise programme had a potentially positive effect on blood glucose regulation, muscle strength and perceived limitations in functioning in patients with diabetic complications.

Diversity of hepatitis B virus infecting Malaysian candidate blood donors is driven by viral and host factors.

Malaysia is a medium endemic country for hepatitis B virus (HBV) infection but little is known about HBV strains circulating in Malaysian blood donors. Viral load, HBsAg concentrations and nested PCR products from 84 HBV surface antigen (HBsAg) positive samples were analysed in detail. Median viral load was 3050 IU/mL and median HBsAg 1150 IU/mL. Fifty-six full genome, 20 pre-S/S, 1 S gene and six basic core promoter/precore-only sequences were obtained. Genotypes B and C were present at a ratio of 2:1, and two genotype D samples were obtained, both from donors of Indian background. Phylogenetically, genotype B was more diverse with subgenotypes B2-5, B7 and B8 present, while most genotype C strains were from subgenotype C1. Genotypes B and C were equally frequent in ethnic Malays, but 80% of strains from Chinese were genotype B. HBsAg concentrations were higher in genotype C than in genotype B, in Chinese than Malays and in donors under the age of 30. HBV vaccine escape substitutions (P120S/T, I126N and G145G) were present in six strains. In the large surface protein, immuno-inactive regions were more mutated than CD8 epitopes and the major hydrophilic region. Strains of genotype B or from ethnic Malays had higher genetic diversity than strains of genotype C or from Chinese donors. Hence HBV strains circulating in Malaysia are phylogenetically diverse reflecting the ethnic mix of its population. Ethnic Malays carry lower HBsAg levels and higher genetic diversity of the surface antigen, possibly resulting in more effective immune control of the infection.

Intracellular invasion by Orientia tsutsugamushi is mediated by integrin signaling and actin cytoskeleton rearrangements.

Orientia tsutsugamushi, the causative agent of scrub typhus, is an obligate intracellular pathogen. Previously, we reported that the 56-kDa type-specific antigen (TSA56), a major outer membrane protein of O. tsutsugamushi, binds to fibronectin and facilitates bacterial entry into the host cell, potentially via an interaction with integrins. Here, we demonstrated that O. tsutsugamushi colocalizes with integrin alpha 5 beta 1 and activates integrin signaling effectors, including focal adhesion kinase, Src kinase, and RhoA GTPase, and also recruits signaling adaptors, such as talin and paxillin, to the site of infection. Inhibition of protein tyrosine kinases or RhoA reduced intracellular invasion. We also observed substantial actin reorganization and membrane protrusions at the sites of infection of nonphagocytic host cells. Finally, we identified a region in the extracellular domain of TSA56 that binds to fibronectin. A peptide containing this region was able to significantly reduce bacterial invasion. Taken together, these results clearly indicate that O. tsutsugamushi exploits integrin-mediated signaling and the actin cytoskeleton for invasion of eukaryotic host cells.

Global gene expression profile of Orientia tsutsugamushi.

Orientia tsutsugamushi, an obligate intracellular bacterium, is the causative agent of Scrub typhus. The control mechanisms for bacterial gene expression are largely unknown. Here, the global gene expression of O. tsutsugamushi within eukaryotic cells was examined using a microarray and proteomic approaches for the first time. These approaches identified 643 genes, corresponding to approximately 30% of the genes encoded in the genome. The majority of expressed genes belonged to several functional categories including protein translation, protein processing/secretion, and replication/repair. We also searched the conserved sequence blocks (CSBs) in the O. tsutsugamushi genome which is unique in that up to 40% of its genome consists of dispersed repeated sequences. Although extensive shuffling of genomic sequences was observed between two different strains, 204 CSBs, covering 48% of the genome, were identified. When combining the data of CSBs and global gene expression, the CSBs correlates well with the location of expressed genes, suggesting the functional conservation between gene expression and genomic location. Finally, we compared the gene expression of the bacteria-infected fibroblasts and macrophages using microarray analysis. Some major changes were the downregulation of genes involved in translation, protein processing and secretion, which correlated with the reduction in bacterial translation rates and growth within macrophages.

Evaluation of endocrine tests. D: the prolonged fasting test for insulinoma.

OBJECTIVE: To establish the diagnostic performance of the prolonged fasting test in patients suspected of insulinoma. METHODS: We included all patients who were referred to our department between August 1995 and August 2006 with a clinical suspicion of insulinoma. Insulinoma was diagnosed by a positive Whipple's triad during the prolonged fast in combination with an insulin/C-peptide ratio below 1. The presence of insulinoma was confirmed by histopathological data, which was considered the golden standard. If the prolonged fast was negative, long-term follow-up was obtained. RESULTS: Ten patients had a positive Whipple's triad during the prolonged fast: eight had a histologically proven insulinoma, and two had factitious hypoglycaemia (insulin/C-peptide ratio >1.0) One additional patient likely had an insulinoma, but the Whipple's triad remained absent at up to 56 hours of fasting. Follow-up (median 53 months (3 to 142) in 76% of patients with a negative fasting test revealed no missed cases of insulinoma. During the prolonged fast the glucose, insulin and C-peptide concentrations overlapped in patients with and without insulinoma. CONCLUSION: In our centre, the prolonged fasting test defined as a positive Whipple's triad in combination with an insulin/C-peptide ratio <1 had a sensitivity of 88.9% and a specificity of 100% for the diagnosis of insulinoma.