A case report of a large right atrial myxoma: the role of virtual consultations and imaging during the COVID-19 pandemic.

We present a case report of a right atrial myxoma first diagnosed on a transthoracic echocardiogram after telephone consultations held in lieu of face-to-face consultations during the first wave of the COVID-19 pandemic. The echocardiogram was requested on the second telephone consultation 3 months after an initial presentation with a dry cough and fatigue due to new symptoms of palpitations and shortness of breath raising suspicion of heart failure. Virtual consultations continue to replace face-to-face consultations to avoid unnecessary exposure to COVID and reduce health care costs. This case report focuses on the importance of obtaining a systematic history, identifying red flags, referring to appropriate specialties and requesting the right investigations for early diagnosis and management of conditions with serious complications.

Oscillations in K(ATP) conductance drive slow calcium oscillations in pancreatic ß-cells.

ATP-sensitive K+ (K(ATP)) channels were first reported in the ß-cells of pancreatic islets in 1984, and it was soon established that they are the primary means by which the blood glucose level is transduced to cellular electrical activity and consequently insulin secretion. However, the role that the K(ATP) channels play in driving the bursting electrical activity of islet ß-cells, which drives pulsatile insulin secretion, remains unclear. One difficulty is that bursting is abolished when several different ion channel types are blocked pharmacologically or genetically, making it challenging to distinguish causation from correlation. Here, we demonstrate a means for determining whether activity-dependent oscillations in K(ATP) conductance play the primary role in driving electrical bursting in ß-cells. We use mathematical models to predict that if K(ATP) is the driver, then contrary to intuition, the mean, peak, and nadir levels of ATP/ADP should be invariant to changes in glucose within the concentration range that supports bursting. We test this in islets using Perceval-HR to image oscillations in ATP/ADP. We find that mean, peak, and nadir levels are indeed approximately invariant, supporting the hypothesis that oscillations in K(ATP) conductance are the main drivers of the slow bursting oscillations typically seen at stimulatory glucose levels in mouse islets. In conclusion, we provide, for the first time to our knowledge, causal evidence for the role of K(ATP) channels not only as the primary target for glucose regulation but also for their role in driving bursting electrical activity and pulsatile insulin secretion.

Slow oscillations persist in pancreatic beta cells lacking phosphofructokinase M.

Pulsatile insulin secretion by pancreatic beta cells is necessary for tight glucose control in the body. Glycolytic oscillations have been proposed as the mechanism for generating the electrical oscillations underlying pulsatile insulin secretion. The glycolytic enzyme 6-phosphofructokinase-1 (PFK) synthesizes fructose-1,6-bisphosphate (FBP) from fructose-6-phosphate. It has been proposed that the slow electrical and Ca2+ oscillations (periods of 3-5 min) observed in islets result from allosteric feedback activation of PFKM by FBP. Pancreatic beta cells express three PFK isozymes: PFKL, PFKM, and PFKP. A prior study of mice that were engineered to lack PFKM using a gene-trap strategy to delete Pfkm produced a mosaic reduction in global Pfkm expression, but the islets isolated from the mice still exhibited slow Ca2+ oscillations. However, these islets still expressed residual PFKM protein. Thus, to more fully test the hypothesis that beta cell PFKM is responsible for slow islet oscillations, we made a beta-cell-specific knockout mouse that completely lacked PFKM. While PFKM deletion resulted in subtle metabolic changes in vivo, islets that were isolated from these mice continued to exhibit slow oscillations in electrical activity, beta cell Ca2+ concentrations, and glycolysis, as measured using PKAR, an FBP reporter/biosensor. Furthermore, simulations obtained with a mathematical model of beta cell activity shows that slow oscillations can persist despite PFKM loss provided that one of the other PFK isoforms, such as PFKP, is present, even if its level of expression is unchanged. Thus, while we believe that PFKM may be the main regulator of slow oscillations in wild-type islets, PFKP can provide functional redundancy. Our model also suggests that PFKM likely dominates, in vivo, because it outcompetes PFKP with its higher FBP affinity and lower ATP affinity. We thus propose that isoform redundancy may rescue key physiological processes of the beta cell in the absence of certain critical genes.

Chop/Ddit3 depletion in ß cells alleviates ER stress and corrects hepatic steatosis in mice.

Type 2 diabetes (T2D) is a metabolic disorder characterized by hyperglycemia, hyperinsulinemia, and insulin resistance (IR). During the early phase of T2D, insulin synthesis and secretion by pancreatic ß cells is enhanced, which can lead to proinsulin misfolding that aggravates endoplasmic reticulum (ER) protein homeostasis in ß cells. Moreover, increased circulating insulin may contribute to fatty liver disease. Medical interventions aimed at alleviating ER stress in ß cells while maintaining optimal insulin secretion are therefore an attractive therapeutic strategy for T2D. Previously, we demonstrated that germline Chop gene deletion preserved ß cells in high-fat diet (HFD)-fed mice and in leptin receptor-deficient db/db mice. In the current study, we further investigated whether targeting Chop/Ddit3 specifically in murine ß cells conferred therapeutic benefits. First, we showed that Chop deletion in ß cells alleviated ß cell ER stress and delayed glucose-stimulated insulin secretion (GSIS) in HFD-fed mice. Second, ß cell-specific Chop deletion prevented liver steatosis and hepatomegaly in aged HFD-fed mice without affecting basal glucose homeostasis. Third, we provide mechanistic evidence that Chop depletion reduces ER Ca2+ buffering capacity and modulates glucose-induced islet Ca2+ oscillations, leading to transcriptional changes of ER chaperone profile ("ER remodeling"). Last, we demonstrated that a GLP1-conjugated Chop antisense oligonucleotide strategy recapitulated the reduction in liver triglycerides and pancreatic insulin content. In summary, our results demonstrate that Chop depletion in ß cells provides a therapeutic strategy to alleviate dysregulated insulin secretion and consequent fatty liver disease in T2D.

Mitophagy protects ß cells from inflammatory damage in diabetes.

Inflammatory damage contributes to ß cell failure in type 1 and 2 diabetes (T1D and T2D, respectively). Mitochondria are damaged by inflammatory signaling in ß cells, resulting in impaired bioenergetics and initiation of proapoptotic machinery. Hence, the identification of protective responses to inflammation could lead to new therapeutic targets. Here, we report that mitophagy serves as a protective response to inflammatory stress in both human and rodent ß cells. Utilizing in vivo mitophagy reporters, we observed that diabetogenic proinflammatory cytokines induced mitophagy in response to nitrosative/oxidative mitochondrial damage. Mitophagy-deficient ß cells were sensitized to inflammatory stress, leading to the accumulation of fragmented dysfunctional mitochondria, increased ß cell death, and hyperglycemia. Overexpression of CLEC16A, a T1D gene and mitophagy regulator whose expression in islets is protective against T1D, ameliorated cytokine-induced human ß cell apoptosis. Thus, mitophagy promotes ß cell survival and prevents diabetes by countering inflammatory injury. Targeting this pathway has the potential to prevent ß cell failure in diabetes and may be beneficial in other inflammatory conditions.

Publisher Correction: IAPP toxicity activates HIF1α/PFKFB3 signaling delaying ß-cell loss at the expense of ß-cell function.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

IAPP toxicity activates HIF1α/PFKFB3 signaling delaying ß-cell loss at the expense of ß-cell function.

The islet in type 2 diabetes (T2D) is characterized by amyloid deposits derived from islet amyloid polypeptide (IAPP), a protein co-expressed with insulin by ß-cells. In common with amyloidogenic proteins implicated in neurodegeneration, human IAPP (hIAPP) forms membrane permeant toxic oligomers implicated in misfolded protein stress. Here, we establish that hIAPP misfolded protein stress activates HIF1α/PFKFB3 signaling, this increases glycolysis disengaged from oxidative phosphorylation with mitochondrial fragmentation and perinuclear clustering, considered a protective posture against increased cytosolic Ca2+ characteristic of toxic oligomer stress. In contrast to tissues with the capacity to regenerate, ß-cells in adult humans are minimally replicative, and therefore fail to execute the second pro-regenerative phase of the HIF1α/PFKFB3 injury pathway. Instead, ß-cells in T2D remain trapped in the pro-survival first phase of the HIF1α injury repair response with metabolism and the mitochondrial network adapted to slow the rate of cell attrition at the expense of ß-cell function.

The ATPase activity of Asna1/TRC40 is required for pancreatic progenitor cell survival.

Asna1, also known as TRC40, is implicated in the delivery of tail-anchored (TA) proteins into the endoplasmic reticulum (ER), in vesicle-mediated transport, and in chaperoning unfolded proteins during oxidative stress/ATP depletion. Here, we show that Asna1 inactivation in pancreatic progenitor cells leads to redistribution of the Golgi TA SNARE proteins syntaxin 5 and syntaxin 6, Golgi fragmentation, and accumulation of cytosolic p62+ puncta. Asna1-/- multipotent progenitor cells (MPCs) selectively activate integrated stress response signaling and undergo apoptosis, thereby disrupting endocrine and acinar cell differentiation, resulting in pancreatic agenesis. Rescue experiments implicate the Asna1 ATPase activity and a CXXC di-cysteine motif in ensuring Golgi integrity, syntaxin 5 localization and MPC survival. Ex vivo inhibition of retrograde transport reproduces the perturbed Golgi morphology, and syntaxin 5 and syntaxin 6 expression, whereas modulation of p53 activity, using PFT-α and Nutlin-3, prevents or reproduces apoptosis in Asna1-deficient and wild-type MPCs, respectively. These findings support a role for the Asna1 ATPase activity in ensuring the survival of pancreatic MPCs, possibly by counteracting p53-mediated apoptosis.

Lower Extremity Permanent Dialysis Vascular Access.

Hemodialysis remains the most commonly used RRT option around the world. Technological advances, superior access to care, and better quality of care have led to overall improvement in survival of patients on long-term hemodialysis. Maintaining a functioning upper extremity vascular access for a prolonged duration continues to remain a challenge for dialysis providers. Frequently encountered difficulties in clinical practice include (1) a high incidence of central venous catheter-related central vein stenosis and (2) limited options for creating a functioning upper extremity permanent arteriovenous access. Lack of surgical skills, fear of complications, and limited involvement of the treating nephrologists in the decision-making process are some of the reasons why lower extremity permanent dialysis access remains an infrequently used option. Similar to upper extremity vascular access options, lower extremity arteriovenous fistula remains a preferred access over arteriovenous synthetic graft. The use of femoral tunneled catheter as a long-term access should be avoided as far as possible, especially with the availability of newer graft-catheter hybrid devices. Our review provides a summary of clinical evidence published in surgical, radiology, and nephrology literature highlighting the pros and cons of different types of lower extremity permanent dialysis access.

Asna1/TRC40 Controls ß-Cell Function and Endoplasmic Reticulum Homeostasis by Ensuring Retrograde Transport.

Type 2 diabetes (T2D) is characterized by insulin resistance and ß-cell failure. Insulin resistance per se, however, does not provoke overt diabetes as long as compensatory ß-cell function is maintained. The increased demand for insulin stresses the ß-cell endoplasmic reticulum (ER) and secretory pathway, and ER stress is associated with ß-cell failure in T2D. The tail recognition complex (TRC) pathway, including Asna1/TRC40, is implicated in the maintenance of endomembrane trafficking and ER homeostasis. To gain insight into the role of Asna1/TRC40 in maintaining endomembrane homeostasis and ß-cell function, we inactivated Asna1 in ß-cells of mice. We show that Asna1(ß-/-) mice develop hypoinsulinemia, impaired insulin secretion, and glucose intolerance that rapidly progresses to overt diabetes. Loss of Asna1 function leads to perturbed plasma membrane-to-trans Golgi network and Golgi-to-ER retrograde transport as well as to ER stress in ß-cells. Of note, pharmacological inhibition of retrograde transport in isolated islets and insulinoma cells mimicked the phenotype of Asna1(ß-/-) ß-cells and resulted in reduced insulin content and ER stress. These data support a model where Asna1 ensures retrograde transport and, hence, ER and insulin homeostasis in ß-cells.

Night blood pressure responses to atenolol and hydrochlorothiazide in black and white patients with essential hypertension.

BACKGROUND: Night blood pressure (BP) predicts patient outcomes. Variables associated with night BP response to antihypertensive agents have not been fully evaluated in essential hypertension. METHODS: We sought to measure night BP responses to hydrochlorothiazide (HCTZ), atenolol (ATEN), and combined therapy using ambulatory blood pressure (ABP) monitoring in 204 black and 281 white essential hypertensive patients. Initial therapy was randomized; HCTZ and ATEN once daily doses were doubled after 3 weeks and continued for 6 more weeks with the alternate medication added for combined therapy arms. ABP was measured at baseline and after completion of each drug. Night, day, and night/day BP ratio responses (treatment - baseline) were compared in race/sex subgroups. RESULTS: Baseline night systolic BP and diastolic BP, and night/day ratios were greater in blacks than whites (P < 0.01, all comparisons). Night BP responses to ATEN were absent and night/day ratios increased significantly in blacks (P < 0.05). At the end of combined therapy, women, blacks, and those starting with HCTZ as opposed to ATEN had significantly greater night BP responses (P < 0.01). Variables that significantly associated with ATEN response differed from those that associated with HCTZ response and those that associated with night BP response differed from those that associated with day BP response. CONCLUSIONS: In summary, after completion of HCTZ and ATEN therapy, women, blacks, and those who started with HCTZ had greater night BP responses. Reduced night BP response and increased night/day BP ratios occured with ATEN in blacks. Given the prognostic significance of night BP, strategies for optimizing night BP antihypertensive therapy should be considered. CLINICAL TRIAL REGISTRATION: Clinicaltrials.gov identifier NCT00246519.

Impact of abdominal obesity on incidence of adverse metabolic effects associated with antihypertensive medications.

We assessed adverse metabolic effects of atenolol and hydrochlorothiazide among hypertensive patients with and without abdominal obesity using data from a randomized, open-label study of hypertensive patients without evidence of cardiovascular disease or diabetes mellitus. Intervention included randomization to 25 mg of hydrochlorothiazide or 100 mg of atenolol monotherapy followed by their combination. Fasting glucose, insulin, triglycerides, high-density lipoprotein cholesterol, and uric acid levels were measured at baseline and after monotherapy and combination therapy. Outcomes included new occurrence of and predictors for new cases of glucose > or =100 mg/dL (impaired fasting glucose), triglyceride > or =150 mg/dL, high-density lipoprotein < or =40 mg/dL for men or < or =50 mg/dL for women, or new-onset diabetes mellitus according to the presence or absence of abdominal obesity. Abdominal obesity was present in 167 (58%) of 395 patients. Regardless of strategy, in those with abdominal obesity, 20% had impaired fasting glucose at baseline compared with 40% at the end of study (P<0.0001). Proportion with triglycerides > or =150 mg/dL increased from 33% at baseline to 46% at the end of study (P<0.01). New-onset diabetes mellitus occurred in 13 patients (6%) with and in 4 patients (2%) without abdominal obesity. Baseline levels of glucose, triglyceride, and high-density lipoprotein predicted adverse outcomes, and predictors for new-onset diabetes mellitus after monotherapy in those with abdominal obesity included hydrochlorothiazide strategy (odds ratio: 46.91 [95% CI: 2.55 to 862.40]), female sex (odds ratio: 31.37 [95% CI: 2.10 to 468.99]), and uric acid (odds ratio: 3.19 [95% CI: 1.35 to 7.52]). Development of adverse metabolic effect, including new-onset diabetes mellitus associated with short-term exposure to hydrochlorothiazide and atenolol was more common in those with abdominal obesity.

Differentiation of human umbilical cord blood-derived mononuclear cells to endocrine pancreatic lineage.

Generation of insulin-producing cells remains a major limitation for cellular replacement therapy in treatment of diabetes. To understand the potential of human umbilical cord blood (hUCB)-derived mononuclear cells (MNCs) in cell replacement therapy for diabetes, we studied MNCs isolated from 270 human umbilical cord blood samples. We characterized these by immunostaining and real-time PCR and studied their ability to differentiate into insulin-producing cells. We observe that freshly isolated MNCs as well as mesenchymal-like cells grown out by in vitro culture of isolated MNCs express key pancreatic transcription factors: pdx1, ngn3, isl1, brn4 and pax6. However, after 32-fold expansion, MNCs show decreased abundance of pdx1 and ngn3, indicating that islet/pancreatic progenitors detected in freshly isolated MNCs die or are diluted out during in vitro expansion. We therefore transplanted freshly isolated MNCs in NOD/SCID (immuno-incompetent) or FVB/NJ (immuno-competent) mice to check their ability to differentiate into insulin-producing cells. We observe that after 9 weeks of transplantation, approximately 25% grafts exhibit human insulin-producing (16% immunopositive) cells. The number and abundance of pro-insulin transcript-containing cells increased when the animals underwent partial pancreatectomy, 15 days after transplantation. Our results indicate that such hUCB-derived MNC population contains a subset of "pancreas-committed" cells that have the potential to differentiate into insulin-producing cells in vivo. Further studies in understanding the differentiation potential of this subset of pancreas-committed hUCB-derived MNCs will provide us with an autologous source of "lineage-committed" progenitors for cell replacement therapy in diabetes.

New pancreas from old: microregulators of pancreas regeneration.

MicroRNAs (miRNAs) are 18-22 nucleotide RNA molecules that mediate post-transcriptional gene silencing, primarily by binding to the 3' untranslated region of their target mRNA. Several studies have demonstrated the role of miRNAs in mouse pancreas development (miR-124a, miR-503, miR-541, miR-214) as well as in insulin secretion (miR-375, miR-9). Pancreatic transcription factors that are temporally expressed during early pancreas development are re-expressed during pancreas regeneration following pancreatectomy in mice. The only exception to this is Neurogenin3 (NGN3). Here, we discuss recent evidence for miRNA-mediated silencing of ngn3, which inhibits endocrine cell development via the classical 'stem cell pathway' during mouse pancreatic regeneration, thereby favoring beta-cell regeneration.

MicroRNA profiling of developing and regenerating pancreas reveal post-transcriptional regulation of neurogenin3.

The mammalian pancreas is known to show a remarkable degree of regenerative ability. Several studies until now have demonstrated that the mammalian pancreas can regenerate in normal as well as diabetic conditions. These studies illustrate that pancreatic transcription factors that are seen to be expressed in a temporal fashion during development are re-expressed during regeneration. The only known exception to this is Neurogenin3 (NGN3). Though NGN3 protein, which marks all the pro-endocrine cells during development, is not seen during mouse pancreas regeneration, functional neo-islets are generated by 4 weeks after 70% pancreatectomy. We observed that pancreatic transcription factors upstream of ngn3 showed similar gene expression patterns during development and regeneration. However, gene transcripts of transcription factors immediately downstream of ngn3 (neuroD and nkx2.2) did not show such similarities in expression. Since NGN3 protein was not detected at any time point during regeneration, we reasoned that post-transcriptional silencing of ngn3 by microRNAs may be a possible mechanism. We carried out microRNA analysis of 283 known and validated mouse microRNAs during different stages of pancreatic development and regeneration and identified that 4 microRNAs; miR-15a, miR-15b, miR-16 and miR-195, which can potentially bind to ngn3 transcript, are expressed at least 200-fold higher in the regenerating mouse pancreas as compared to embryonic day (e) 10.5 or e 16.5 developing mouse pancreas. Inhibition of these miRNAs in regenerating pancreatic cells using anti-sense miRNA-specific inhibitors, induces expression of NGN3 and its downstream players: neuroD and nkx2.2. Similarly, overexpression of miRNAs targeting ngn3 during pancreas development shows reduction in the number of hormone-producing cells. It appears that during pancreatic regeneration in mice, increased expression of these microRNAs allows endocrine regeneration via an alternate pathway that does not involve NGN3 protein. Our studies on microRNA profiling of developing and regenerating pancreas provide us with better understanding of mechanisms that regulate post-natal islet neogenesis.

Close-packed noncircular nanodevice pattern generation by self-limiting ion-mill process.

We describe a self-limiting, low-energy argon-ion-milling process that enables noncircular device patterns, such as squares or hexagons, to be formed using precursor arrays of uniform circular openings in poly(methyl methacrylate) defined using electron beam lithography. The proposed patterning technique is of particular interest for bit-patterned magnetic recording medium fabrication, where square magnetic bits result in improved recording system performance. Bit-patterned magnetic medium is among the primary candidates for the next generation magnetic recording technologies and is expected to extend the areal bit density limits far beyond 1 Tbit/in(2). The proposed patterning technology can be applied either for direct medium prototyping or for manufacturing of nanoimprint lithography templates or ion beam lithography stencil masks that can be utilized in mass production.