Bile acid metabolism is altered in those with insulin resistance after gestational diabetes mellitus.

BACKGROUND: Bile acids (BAs) are known mediators of glucose metabolism that are altered in type 2 diabetes mellitus (T2DM) and gestational diabetes mellitus (GDM). We hypothesised that post-prandial BA fractions are changed in women with Insulin resistance (IR) after recovery from GDM using homeostatic model assessment (HOMA-IR). METHODS: 45 women median age 44(31-47) with previous GDM, including 20 with HOMA-IR >2.8 and 25 age-matched controls with HOMA-IR ≤ 2.8 were studied. After an overnight fast, all underwent an oral glucose tolerance test. Blood samples were collected at baseline and every 30 min for 120 min and analysed for glucose on automated platform and for total BAs, their conjugates and fractions using liquid-chromatography tandem mass-spectrometry. Baseline samples were analysed for insulin on automated platform. Delta (Δ) change (difference between baseline and maximal post-prandial response) were calculated. Data is presented as median (IQR). RESULTS: Fasting primary and unconjugated BAs were higher in women with HOMA-IR >2.8 vs. those with HOMA-IR ≤ 2.8 [0.24 (0.16-0.33) vs 0.06(0.04-0.22) µmol/L and 0.91(0.56-1.84) µmol/L vs. 0.69(0.32-0.89) µmol/L respectively. ∆ taurine-conjugated BAs was higher in women with HOMA-IR ≤ 2.8 than those with HOMA-IR > 2.8 [0.33(0.20-0.54) vs 0.23(0.13-0.34) µmol/L]. Fasting glucose and non-12α-hydroxylated BAs were negatively correlated in women with HOMA-IR >2.8 (all p < 0.05). CONCLUSIONS: Following GDM, individuals with HOMA-IR >2.8 have altered conjugated and non-12α-hydroxylated fractions of BAs. It remains to be elucidated if the altered BA metabolism is a contributing factor to the pathogenesis or a consequence of GDM.

Metformin in non-diabetic hyperglycaemia: the GLINT feasibility RCT.

BACKGROUND: The treatment of people with diabetes with metformin can reduce cardiovascular disease (CVD) and may reduce the risk of cancer. However, it is unknown whether or not metformin can reduce the risk of these outcomes in people with elevated blood glucose levels below the threshold for diabetes [i.e. non-diabetic hyperglycaemia (NDH)]. OBJECTIVE: To assess the feasibility of the Glucose Lowering In Non-diabetic hyperglycaemia Trial (GLINT) and to estimate the key parameters to inform the design of the full trial. These parameters include the recruitment strategy, randomisation, electronic data capture, postal drug distribution, retention, study medication adherence, safety monitoring and remote collection of outcome data. DESIGN: A multicentre, individually randomised, double-blind, parallel-group, pragmatic, primary prevention trial. Participants were individually randomised on a 1 : 1 basis, blocked within each site. SETTING: General practices and clinical research facilities in Cambridgeshire, Norfolk and Leicestershire. PARTICIPANTS: Males and females aged ≥ 40 years with NDH who had a high risk of CVD. INTERVENTIONS: Prolonged-release metformin (500 mg) (Glucophage® SR, Merck KGaA, Bedfont Cross, Middlesex, UK) or the matched placebo, up to three tablets per day, distributed by post. MAIN OUTCOME MEASURES: Recruitment rates; adherence to study medication; laboratory results at baseline and 3 and 6 months; reliability and acceptability of study drug delivery; questionnaire return rates; and quality of life. RESULTS: We sent 5251 invitations, with 511 individuals consenting to participate. Of these, 249 were eligible and were randomised between March and November 2015 (125 to the metformin group and 124 to the placebo group). Participants were followed up for 0.99 years [standard deviation (SD) 0.30 years]. The use of electronic medical records to identify potentially eligible individuals in individual practices was resource intensive. Participants were generally elderly [mean age 70 years (SD 6.7 years)], overweight [mean body mass index 30.1 kg/m2 (SD 4.5 kg/m2)] and male (88%), and the mean modelled 10-year CVD risk was 28.8% (SD 8.5%). Randomisation, postal delivery of the study drug and outcome assessment using registers/medical records were feasible and acceptable to participants. Most participants were able to take three tablets per day, but premature discontinuation of the study drug was common (≈30% of participants by 6 months), although there were no differences between the groups. All randomised participants returned questionnaires at baseline and 67% of participants returned questionnaires by the end of the study. There was no between-group difference in Short Form questionnaire-8 items or EuroQol-5 Dimensions scores. Compared with placebo, metformin was associated with small improvements in the mean glycated haemoglobin level [-0.82 mmol/mol, 95% confidence interval (CI) -1.39 to -0.24 mmol/mol], mean estimated glomerular filtration rate (2.31 ml/minute/1.73 m2, 95% CI -0.2 to 4.81 ml/minute/1.73 m2) and mean low-density lipoprotein cholesterol level (-0.11 mmol/l, 95% CI -0.25 to 0.02 mmol/l) and a reduction in mean plasma vitamin B12 level (-16.4 ng/l, 95% CI -32.9 to -0.01 ng/l). There were 35 serious adverse events (13 in the placebo group, 22 in the metformin group), with none deemed to be treatment related. LIMITATIONS: Changes to sponsorship reduced the study duration, the limited availability of information in medical records reduced recruitment efficiency and discontinuation of study medication exceeded forecasts. CONCLUSIONS: A large, pragmatic trial comparing the effects of prolonged-release metformin and placebo on the risk of CVD events is potentially feasible. However, changes to the study design and conduct are recommended to enable an efficient scaling up of the trial. Recommendations include changing the inclusion criteria to recruit people with pre-existing CVD to increase the recruitment and event rates, using large primary/secondary care databases to increase recruitment rates, conducting follow-up remotely to improve efficiency and including a run-in period prior to randomisation to optimise trial adherence. TRIAL REGISTRATION: Current Controlled Trials ISRCTN34875079. FUNDING: The project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 18. See the NIHR Journals Library website for further project information. Merck KGaA provided metformin and matching placebo.

Polymorphic differences in the SOD-2 gene may affect the pathogenesis of nephropathy in patients with diabetes and diabetic complications.

UNLABELLED: The effective treatment of diabetes and the prevention of diabetic complications may be improved by a better understanding of the antioxidant function of intracellular defences against oxidative stress. Polymorphisms in antioxidant genes may determine cellular oxidative stress levels as a primary pathogenic role in diabetes and/or in its complications. SOD-2 was investigated in patients with type 1 diabetes mellitus (T1DM) to ascertain if specific genotypes have any protective influences in the pathogenic mechanisms in diabetes and/or in several different complications, including retinopathy, nephropathy and diabetic controls compared to normal healthy controls. METHOD: 278 (136M:142F) T1DM patients and 135 (72M:63F) normal, healthy controls were investigated for SOD-2 polymorphism in the mitochondrial targeting sequence with Ala/Val (C-9T) substitution. RESULTS: A significant difference in the C-9-T genotype was observed between patients and normal controls but not between diabetic controls and patients with complications. There were significantly more of the diabetic control (DC, n=62) group (11.3%) than the patients with diabetic nephropathy (DN, n=73) (1.4%) with the CC genotype (p=0.03 and χ(2)=4.27, OR=9.16 (1.08

p21(WAF1/CIP1) Expression is Differentially Regulated by Metformin and Rapamycin.

The mammalian target of rapamycin (mTOR) pathway plays an important role in the development of diabetic nephropathy and other age-related diseases. One of the features of DN is the elevated expression of p21(WAF1/CIP1). However, the importance of the mTOR signalling pathway in p21 regulation is poorly understood. Here we investigated the effect of metformin and rapamycin on mTOR-related phenotypes in cell lines of epithelial origin. This study reports that metformin inhibits high glucose-induced p21 expression. High glucose opposed metformin in regulating cell size, proliferation, and protein synthesis. These effects were associated with reduced AMPK activation, affecting downstream mTOR signalling. However, the inhibition of the mTOR pathway by rapamycin did not have a negative effect on p21 expression, suggesting that metformin regulates p21 upstream of mTOR. These findings provide support for the hypothesis that AMPK activation may regulate p21 expression, which may have implications for diabetic nephropathy and other age-related pathologies.

AKR1B10 is induced by hyperglycaemia and lipopolysaccharide in patients with diabetic nephropathy.

Aldose reductase family member B10 (AKR1B10) belongs to the aldo-keto reductase gene superfamily and is closely related to aldose reductase (AKR1B1). It has been shown that AKR1B10 is present in many of the same human tissues as AKR1B1. The objective of this study was to investigate whether AKR1B10 has a role in diabetic nephropathy (DN) by investigating its response to high glucose and inflammation, both of which have been associated with the development and progression of DN. Expression levels of AKR1B10 were determined in peripheral blood mononuclear cells (PBMCs) obtained from 25 patients with type 1 diabetes and nephropathy, 25 without DN and 25 normal healthy controls that were exposed to high glucose (25 mM D-glucose) and also the inflammatory stressor lipopolysaccharide (LPS, 10 µm). Under high glucose and LPS conditions, there was a significant increase in the expression of AKR1B10 in the PBMCs from patients with DN compared to those without DN and the normal controls. In conclusion, these results suggest that AKR1B10 may have an important role in the development and progression of DN.

Hydrogen sulfide induces heme oxygenase-1 in human kidney cells.

Hydrogen sulfide (H2S) has been shown to have a potential protective role in a number of disease states including diabetes and various kidney disorders; however, the mechanisms involved are still unclear. The aim of this study was to investigate if H2S effects the expression of the antioxidant enzyme heme oxygenase-1 (HO-1) in human kidney cells. Human mesangial cells and human podocytes were cultured at normal physiological glucose concentration (5.5 mM) and then treated with different H2S donors for a 24-h period. Protein was then extracted from the cells, and the expression levels of HO-1 determined by Western blotting. There was a significant increase in HO-1 expression after treatment with the H2S donors in both mesangial and podocyte cells. These results suggest that H2S has a role in the regulation of HO-1 expression, and the ability to upregulate this antioxidant enzyme maybe a potential mechanism by which H2S exerts its protective effects.

Raising awareness of polycystic ovary syndrome.

AIM: To identify women's experience of receiving information about polycystic ovary syndrome (PCOS), and develop an information booklet. METHOD: Women from Cornwall with a diagnosis of PCOS participated in focus groups to discuss their experiences of the condition. FINDINGS: Participants described difficulties in sourcing credible and helpful information about PCOS. CONCLUSION: A booklet was produced for women with PCOS to improve their knowledge of the condition.

A predominantly neolithic origin for European paternal lineages.

The relative contributions to modern European populations of Paleolithic hunter-gatherers and Neolithic farmers from the Near East have been intensely debated. Haplogroup R1b1b2 (R-M269) is the commonest European Y-chromosomal lineage, increasing in frequency from east to west, and carried by 110 million European men. Previous studies suggested a Paleolithic origin, but here we show that the geographical distribution of its microsatellite diversity is best explained by spread from a single source in the Near East via Anatolia during the Neolithic. Taken with evidence on the origins of other haplogroups, this indicates that most European Y chromosomes originate in the Neolithic expansion. This reinterpretation makes Europe a prime example of how technological and cultural change is linked with the expansion of a Y-chromosomal lineage, and the contrast of this pattern with that shown by maternally inherited mitochondrial DNA suggests a unique role for males in the transition.

Assessing the impact of a new delivery method of insulin on glycemic control using a novel trial design.

OBJECTIVE: The purpose of the trial was to examine the impact of inhaled human insulin (INH) on patient or physician willingness to adopt insulin after oral diabetes agent failure. RESEARCH DESIGN AND METHODS: The EXPERIENCE trial was a one-year randomized controlled trial conducted at primary, secondary and tertiary care facilities in Europe and North America. The primary study endpoint was difference in glycated hemoglobin (A(1c)) between randomized groups at 26 weeks, and results from that phase have been reported previously. The present report concerns results from the second 26-week extension phase. We also consider the applicability of the design. The trial recruited 727 patients with type 2 diabetes mellitus who, prior to randomization, were using two or more oral diabetes agents and whose A(1c) was ≥ 8.0%. Patients were randomized to two treatment settings: Group 1 (usual care with the option of INH) or Group 2 (usual care only). Usual care included adjusting oral therapy (optimizing current regimen or adding/deleting agents) and/or initiating subcutaneous (SC) insulin. RESULTS: At baseline, insulin was initiated by more (odds ratio [OR] 6.0;95% confidence interval [CI] 4.2 to 8.8; P < 0.0001) patients in Group 1 (86.2%; 76.7% INH plus 9.5% SC) than in Group 2 (50.7%; SC insulin only). The largest reduction from baseline in A(1c) was in Group 1 (-2.0 ± 1.2%) at Week 12 and in Group 2 (-1.8 ± 1.3%) at Week 26 (P = 0.003). At 52 weeks, 79.8% were on insulin in Group 1 (67.4% INH; 12.4% SC) vs 58.1% (SC only) in Group 2, and mean (SD) changes in A(1c) from baseline were -1.9% (1.2%) and -1.8% (1.3%) in Groups 1 and 2, respectively (P = 0.05). Hypoglycemic event rates per patient month were 0.3 and 0.1 in Groups 1 and 2, respectively (P < 0.0001). CONCLUSION: The EXPERIENCE trial showed that novel delivery technology can accelerate the adoption of insulin although some attenuation of differences is observed over time. And further, that this was achieved in a population of patients who appeared more ready to move to insulin therapy than observed in standard clinical practice, and a group of physicians who appeared more ready to adopt INH than the majority of physicians.

Neighborhood deprivation and preterm birth in Plymouth, UK.

OBJECTIVE: To assess the relationship between neighborhood deprivation and the preterm birth rate in Plymouth, UK, using routinely collected data from a clinical information system. METHODS: We used a clinic-based prospective case register study of all births in Plymouth UK between 1 January 1996 and 31 December 1997 combined with indices of neighborhood deprivation to assess the relationship between neighborhood deprivation and the preterm birth rate. Areas (n = 43) were classified according to the Townsend index, measuring material deprivation. Preterm births were compared with term births. RESULTS: The incidence of singleton preterm birth was 5.3% (95% confidence interval (CI) 4.6, 6.0). The singleton preterm birth rate increased with Townsend material deprivation score. Crude rates increased by 31% (relative risk (RR) (95% CI) 1.31 (0.94, 1.84), p = 0.056) among those living in the most deprived areas compared to those living in the least deprived areas. A stepwise binary logistic regression model showed an increase in the relative risk of preterm birth of 7% for every unit increase in the Townsend material deprivation score (RR (95% CI) 1.07 (1.03, 1.11)). CONCLUSION: Neighborhood deprivation is related to preterm birth. Examining individual and neighborhood factors together may increase understanding of the complex causes of preterm birth.

Gestational diabetes mellitus in Plymouth, U.K.: prevalence, seasonal variation and associated factors.

OBJECTIVE: To estimate the prevalence of and associated factors in gestational diabetes mellitus (GDM) and its seasonal variation. STUDY DESIGN: A clinic-based, prospective, case register study was conducted from January 1996 to December 1997. A total of 4,942 consecutive Caucasian, pregnant women aged 15-46 years,free of a history of diabetes mellitus, underwent random plasma glucose screening and a 75-g, 2-hour oral glucose tolerance test in Plymouth, U.K. The mean (SD) age of the women was 28.2 (5.5) years. Women with and without GDM were compared. RESULTS: The prevalence of GDM among the subjects was 1.8% (95% CI 1.4,2.2). The prevalence of GDM increased with the mother's age and random plasma glucose level and decreased with the duration of pregnancy. Using a stepwise binary logistic regression model, older age (relative prevalence [RP] 1.08 [95% CI 1.04, 1.12]) and higher random plasma glucose (RP 2.99 [95% CI 2.51, 3.551) were significant predictors of GDM. The monthly prevalence of GDM ranged from 2.9% (95% CI 1.5, 5.0) in June to 1.1% (95% CI 0.3,2.8) in November. The seasonal GDM rate ranged from 2.3% (95% CI 1.5, 3.2) in spring to 1.4% (95% CI 0.8, 2.3) in winter. The differences were not statistically significant for either the month (p = 0.82) or season (p = 0.41). CONCLUSION: The prevalence (1.8%) of GDM in this representative sample of Caucasian pregnant women was lower than the 3-5% typically reported in other European and North American studies, and there was no seasonal pattern.

How well do midwives estimate the date of delivery?

OBJECTIVE: to compare expected date of delivery (EDD) and gestational age (GA) obtained by midwives with those calculated using the Confidential Enquiry into Stillbirths and Death in Infancy (CESDI) recommended formula. DESIGN: retrospective study of obstetric records and prospective study of clinical cases examined by multiple midwives. SETTING: postnatal wards, Maternity Unit, Plymouth, Devon, UK. PARTICIPANTS: two studies were performed. The first was a retrospective analysis of 115 sets of obstetric records. The second, a prospective study which included five clinical cases and 19 qualified midwives whose experience ranged from six months to 25 years. FINDINGS: in the retrospective study, 68 (59%) of the 115 obstetric case notes had sufficient information to apply the CESDI formula. The midwives'calculated EDD was interpreted to a GA and 35 (52.5%) agreed to within three days of the GA derived from the CESDI formula EDD. In the prospective study, the midwives' calculation of EDD was in good agreement with the CESDI formula in cases where last menstrual period (LMP) was known and menstrual cycle was 28 days with 17 (90%) of the 19 midwives providing the EDD to within three days of the CESDI formula. In the clinical case where LMP was known but menstrual cycle length was 33 days only two (10%) of the 19 calculated the EDD within three days of the CESDI formula. KEY CONCLUSIONS: when LMP is known and the cycle length is 28 days, midwives produce results consistent with the CESDI formula. However, when the menstrual cycle differs from 28 days or LMP is unknown, inaccurate or ambiguous and obstetric ultrasound scan (USS) information is used to calculate the EDD, the midwives show varying degrees of departure from the CESDI formula. Further, we found that the midwives tended to produce underestimates when calculating GA from EDD. This bias occurs across the range of gestations covered, including early gestations when such biases may have more important medical implications. IMPLICATIONS FOR PRACTICE: midwives' calculation of EDD and estimation of GA showed both random and systematic errors; in some cases, the errors were so large that they may have important medical consequences. If the CESDI-recommended formula for calculating EDD were used there would be improved accuracy and reliability of EDD and the calculation of GA.

Variation within the type 2 diabetes susceptibility gene calpain-10 and polycystic ovary syndrome.

Variation within the calpain-10 gene (CAPN10) has been proposed to account for linkage to type 2 diabetes on chromosome 2q in Mexican-Americans, and associations with diabetes have been reported in several other populations. Given the epidemiological, physiological, and genetic overlap between type 2 diabetes and polycystic ovary syndrome (PCOS), CAPN10 represents a strong candidate gene for a role in PCOS susceptibility. Using both family based and case-control association resources (146 parent-offspring trios; 185 additional PCOS cases; 525 control subjects, all of European ancestry), we sought association between CAPN10 variation and PCOS, focusing on four single nucleotide polymorphism (SNP) variants (SNP-44, SNP-43; SNP-19; SNP-63). On single-locus transmission disequilibrium analysis in the 146 trios, there was nominal evidence (P = 0.03) of excess transmission of the more common allele at SNP-63. This association was not, however, replicated in the case-control analysis. No other significant associations were observed at the single-locus or haplotype level in either the transmission-disequilibrium or case-control analyses. The relative risk for the high-risk diabetes susceptibility 112/121 genotype (SNPs 43-19-63) was 0.84 (95% confidence intervals, 0.40-1.71). No associations were seen with intermediate traits of relevance to diabetes and PCOS pathogenesis. We have found no evidence from these analyses that CAPN10 gene variation influences susceptibility to PCOS.