Glucagon-like peptide 1 improved glycemic control in type 1 diabetes

BACKGROUND: Glucagon-like peptide-1 (GLP-1) and its agonists are under assessment in treatment of type 2 diabetes, by virtue of their antidiabetic actions, which include stimulation of insulin secretion, inhibition of glucagon release, and delay of gastric emptying. We examined the potential of GLP-1 to improve glycemic control in type 1 diabetes with no endogenous insulin secretion. METHODS: Dose-finding studies were carried out to establish mid range doses for delay of gastric emptying indicated by postponement of pancreatic polypeptide responses after meals. The selected dose of 0.63 micrograms/kg GLP-1 was administered before breakfast and lunch in 8-hour studies in hospital to establish the efficacy and safety of GLP-1. In outside-hospital studies, GLP-1 or vehicle was self-administered double-blind before meals with usual insulin for five consecutive days by five males and three females with well-controlled C-peptide-negative type 1 diabetes. Capillary blood glucose values were self-monitored before meals, at 30 and 60 min after breakfast and supper, and at bedtime. Breakfast tests with GLP-1 were conducted on the day before and on the day after 5-day studies. Paired t-tests and ANOVA were used for statistical analysis. RESULTS: In 8-hour studies time-averaged incremental (delta) areas under the curves(AUC) for plasma glucose through 8 hours were decreased by GLP-1 compared to vehicle (3.2 ± 0.9, mean ± se, vs 5.4 ± 0.8 mmol/l, p < .05), and for pancreatic polypeptide, an indicator of gastric emptying, through 30 min after meals (4.0 ± 3.1 vs 37 ± 9.6 pmol/l, p < .05) with no adverse effects. Incremental glucagon levels through 60 min after meals were depressed by GLP-1 compared to vehicle (-3.7 ± 2.5 vs 3.1 ± 1.9 ng/l, p < .04). In 5-day studies, AUC for capillary blood glucose levels were lower with GLP-1 than with vehicle (-0.64 ± 0.33 vs 0.34 ± 0.26 mmol/l, p < .05). No assisted episode of hypoglycaemia or change in insulin dosage occurred. Breakfast tests on the days immediately before and after 5-day trials showed no change in the effects of GLP-1. CONCLUSION: We have demonstrated that subcutaneous GLP-1 can improve glucose control in type 1 diabetes without adverse effects when self-administered before meals with usual insulin during established intensive insulin treatment programs

Intracellular immune sensing promotes inflammation via gasdermin D–driven release of a lectin alarmin

Inflammatory caspase sensing of cytosolic lipopolysaccharide (LPS) triggers pyroptosis and the concurrent release of damage-associated molecular patterns (DAMPs). Collectively, DAMPs are key determinants that shape the aftermath of inflammatory cell death. However, the identity and function of the individual DAMPs released are poorly defined. Our proteomics study revealed that cytosolic LPS sensing triggered the release of galectin-1, a β-galactoside-binding lectin. Galectin-1 release is a common feature of inflammatory cell death, including necroptosis. In vivo studies using galectin-1-deficient mice, recombinant galectin-1 and galectin-1-neutralizing antibody showed that galectin-1 promotes inflammation and plays a detrimental role in LPS-induced lethality. Mechanistically, galectin-1 inhibition of CD45 (Ptprc) underlies its unfavorable role in endotoxin shock. Finally, we found increased galectin-1 in sera from human patients with sepsis. Overall, we uncovered galectin-1 as a bona fide DAMP released as a consequence of cytosolic LPS sensing, identifying a new outcome of inflammatory cell death.Fil: Russo, Ashley J.. UConn Health School of Medicine; Estados UnidosFil: Vasudevan, Swathy O.. UConn Health School of Medicine; Estados UnidosFil: Mendez Huergo, Santiago Patricio. Consejo Nacional de Investigaciones Científicas y Técnicas. Instituto de Biología y Medicina Experimental. Fundación de Instituto de Biología y Medicina Experimental. Instituto de Biología y Medicina Experimental; ArgentinaFil: Kumari, Puja. UConn Health School of Medicine; Estados UnidosFil: Menoret, Antoine. UConn Health School of Medicine; Estados UnidosFil: Duduskar, Shivalee. Jena University Hospital; AlemaniaFil: Wang, Chengliang. UConn Health School of Medicine; Estados UnidosFil: Pérez Sáez, Juan Manuel. Consejo Nacional de Investigaciones Científicas y Técnicas. Instituto de Biología y Medicina Experimental. Fundación de Instituto de Biología y Medicina Experimental. Instituto de Biología y Medicina Experimental; ArgentinaFil: Fettis, Margaret M.. University of Florida; Estados UnidosFil: Li, Chuan. UConn Health School of Medicine; Estados UnidosFil: Liu, Renjie. University of Florida; Estados UnidosFil: Wanchoo, Arun. University of Florida; Estados UnidosFil: Chandiran, Karthik. UConn Health School of Medicine; Estados UnidosFil: Ruan, Jianbin. UConn Health School of Medicine; Estados UnidosFil: Vanaja, Sivapriya Kailasan. UConn Health School of Medicine; Estados UnidosFil: Bauer, Michael. Jena University Hospital; AlemaniaFil: Sponholz, Christoph. Jena University Hospital; AlemaniaFil: Hudalla, Gregory A.. University of Florida; Estados UnidosFil: Vella, Anthony T.. UConn Health School of Medicine; Estados UnidosFil: Zhou, Beiyan. UConn Health School of Medicine; Estados UnidosFil: Deshmukh, Sachin D.. Jena University Hospital; AlemaniaFil: Rabinovich, Gabriel Adrián. Consejo Nacional de Investigaciones Científicas y Técnicas. Instituto de Biología y Medicina Experimental. Fundación de Instituto de Biología y Medicina Experimental. Instituto de Biología y Medicina Experimental; ArgentinaFil: Rathinam, Vijay A.. UConn Health School of Medicine; Estados Unido

Comparison of Sequential Three-Drug Regimens as Initial Therapy for HIV-1 Infection

BACKGROUND The optimal sequencing ofantiretroviral regimens for the treatment of infection with human immunodeficiency virus type 1 (HIV-1) is unknown. We compared several different antiretroviral treatment strategies. METHODS This multicenter, randomized, partially double-blind trial used a factorial design to compare pairs of sequential three-drug regimens, starting with a regimen including zidovudine and lamivudine or a regimen including didanosine and stavudine in combination with either nelfinavir or efavirenz. The primary end point was the length of time to the failure ofthe second three-drug regimen. RESULTS A total of 620 subjects who had not previously received antiretroviral therapy were followed for a median of 2. 3 years. Starting with a three-drug regimen containing efavirenz combined with zidovudine and lamivudine (but not efavirenz combined with didanosine and stavudine) appeared to delay the failure ofthe second regimen, as compared with starting with a regimen containing nelfinavir (hazard ratio for failure ofthe second regimen, 0.71; 95 percent confidence interval, 0.48 to 1.06), as well as to delay the second virologic failure (hazard ratio, 0.56; 95 percent confidence interval, 0.29 to 1.09), and significantly delayed the failure ofthe first regimen (hazard ratio, 0.39) and the firstvirologic failure (hazard ratio, 0.34). Starting with zidovudine and lamivudine combined with efavirenz (but not zidovudine and lamivudine combined with nelfinavir) appeared to delay the failure of the second regimen, as compared with starting with didanosine and stavudine (hazard ratio, 0.68), and significantly delayed both the first and the second virologic failures (hazard ratio for the firstvirologic failure, 0.39; hazard ratio for the second virologic failure, 0.47), as well as the failure ofthe first regimen (hazard ratio, 0.35). The initial use of zidovudine, lamivudine, and efavirenz resulted in a shorter time to viral suppression. CONCLUSIONS The efficacy ofantiretroviral drugs depends on how they are combined. The combination of zidovudine, lamivudine, and efavirenz is superior to the other antiretroviral regimens used as initial therapy in this study

Barriers for Access to New Medicines: Searching for the Balance Between Rising Costs and Limited Budgets

Introduction: There is continued unmet medical need for new medicines across countries especially for cancer, immunological diseases and orphan diseases. However, there are growing challenges with funding new medicines at ever increasing prices along with funding increased medicine volumes with the growing prevalence of both infectious diseases and non-communicable diseases across countries. This has resulted in the development of new models to better manage the entry of new medicines, new financial models being postulated as well as strategies to improve prescribing efficiency. However, more needs to be done. Consequently, the primary aim of this paper is to consider potential ways to optimise the use of new medicines balancing rising costs with increasing budgetary pressures to stimulate debate especially from a payer perspective. Methods: A narrative review of pharmaceutical policies and implications, as well as possible developments, based on key publications and initiatives known to the co-authors principally from a health authority perspective. Results: A number of initiatives and approaches have been identified including new models to better manage the entry of new medicines based on three pillars (pre-, peri-, and post-launch activities). Within this, we see the growing role of horizon scanning activities starting up to 36 months before launch, managed entry agreements and post launch follow-up. It is also likely there will be greater scrutiny over the effectiveness and value of new cancer medicines given ever increasing prices. This could include establishing minimum effectiveness targets for premium pricing along with re-evaluating prices as more medicines for cancer lose their patent. There will also be a greater involvement of patients especially with orphan diseases. New initiatives could include a greater role of multicriteria decision analysis, as well as looking at the potential for de-linking research and development from commercial activities to enhance affordability. Conclusion: There are a number of ongoing activities across countries to try and fund new valued medicines whilst attaining or maintaining universal healthcare. Such activities will grow with increasing resource pressures and continued unmet need

Development and Validation of a Risk Score for Chronic Kidney Disease in HIV Infection Using Prospective Cohort Data from the D:A:D Study

Ristola M. on työryhmien DAD Study Grp ; Royal Free Hosp Clin Cohort ; INSIGHT Study Grp ; SMART Study Grp ; ESPRIT Study Grp jäsen.Background Chronic kidney disease (CKD) is a major health issue for HIV-positive individuals, associated with increased morbidity and mortality. Development and implementation of a risk score model for CKD would allow comparison of the risks and benefits of adding potentially nephrotoxic antiretrovirals to a treatment regimen and would identify those at greatest risk of CKD. The aims of this study were to develop a simple, externally validated, and widely applicable long-term risk score model for CKD in HIV-positive individuals that can guide decision making in clinical practice. Methods and Findings A total of 17,954 HIV-positive individuals from the Data Collection on Adverse Events of Anti-HIV Drugs (D:A:D) study with >= 3 estimated glomerular filtration rate (eGFR) values after 1 January 2004 were included. Baseline was defined as the first eGFR > 60 ml/min/1.73 m2 after 1 January 2004; individuals with exposure to tenofovir, atazanavir, atazanavir/ritonavir, lopinavir/ritonavir, other boosted protease inhibitors before baseline were excluded. CKD was defined as confirmed (>3 mo apart) eGFR In the D:A:D study, 641 individuals developed CKD during 103,185 person-years of follow-up (PYFU; incidence 6.2/1,000 PYFU, 95% CI 5.7-6.7; median follow-up 6.1 y, range 0.3-9.1 y). Older age, intravenous drug use, hepatitis C coinfection, lower baseline eGFR, female gender, lower CD4 count nadir, hypertension, diabetes, and cardiovascular disease (CVD) predicted CKD. The adjusted incidence rate ratios of these nine categorical variables were scaled and summed to create the risk score. The median risk score at baseline was -2 (interquartile range -4 to 2). There was a 1: 393 chance of developing CKD in the next 5 y in the low risk group (risk score = 5, 505 events), respectively. Number needed to harm (NNTH) at 5 y when starting unboosted atazanavir or lopinavir/ritonavir among those with a low risk score was 1,702 (95% CI 1,166-3,367); NNTH was 202 (95% CI 159-278) and 21 (95% CI 19-23), respectively, for those with a medium and high risk score. NNTH was 739 (95% CI 506-1462), 88 (95% CI 69-121), and 9 (95% CI 8-10) for those with a low, medium, and high risk score, respectively, starting tenofovir, atazanavir/ritonavir, or another boosted protease inhibitor. The Royal Free Hospital Clinic Cohort included 2,548 individuals, of whom 94 individuals developed CKD (3.7%) during 18,376 PYFU (median follow-up 7.4 y, range 0.3-12.7 y). Of 2,013 individuals included from the SMART/ESPRIT control arms, 32 individuals developed CKD (1.6%) during 8,452 PYFU (median follow-up 4.1 y, range 0.6-8.1 y). External validation showed that the risk score predicted well in these cohorts. Limitations of this study included limited data on race and no information on proteinuria. Conclusions Both traditional and HIV-related risk factors were predictive of CKD. These factors were used to develop a risk score for CKD in HIV infection, externally validated, that has direct clinical relevance for patients and clinicians to weigh the benefits of certain antiretrovirals against the risk of CKD and to identify those at greatest risk of CKD.Peer reviewe

Sustaining the change agent : bringing the body into language in professional practice

In the Introduction to Volatile Bodies, feminist philosopher Elizabeth Grosz announced that the book was a 'kind of experiment in inversion', based on a wager that 'bodies have all the explanatory power of minds' (Grosz 1994, p. vii). The purpose of this wager was to displace the centrality of 'mind, psyche, interior, and consciousness' in conceptions of subjectivity through a reconfiguration of the body. In this chapter we take up this stance of body as method in order to explore the body in professional practice. The structure of the chapter is based on pivotal conversations between the two authors in the process of doctoral supervision. It is written through key conversations when the body made its presence felt. The conversations we re-enact in this chapter are hesitant and discontinuous, each representing a performance of the pivotal moments of coming to understand the power of the body in professional practice

Assessing the human dimensions of the Great Barrier Reef: An Eastern Cape York Region focus

This report focuses on the trial of a regionally-specific framework to assess and monitor the human dimensions of the Great Barrier Reef (GBR) as they relate to Eastern Cape York (ECY) and the adjacent GBR. To ensure GBR policy makers and managers better consider the needs of GBR-dependent and GBR-associated communities and industries, the aim of this project is to develop a participatory approach to the assessment, monitoring and bench-marking of human dimensions of relevance to the region and to the GBR. In considering the area’s human dimensions, the project team has gathered evidence from peer-reviewed literature, the grey literature and other forms of knowledge such as Indigenous, historical and local knowledge. The process involves synthesising evidence from diverse sources, presenting the evidence as a series of tables, and allocating draft scores to attributes of each key human dimension theme or cluster. The tables and proposed scores are to be discussed in regional expert panel meetings using a consistent set of decision rules for scoring regional resilience based on available evidence

Trialling an assessment and monitoring program for the human dimensions of the reef 2050 integrated monitoring and reporting program

The Great Barrier Reef (GBR) is recognised as one of Australia’s and the worlds’ great natural treasures. It also provides many social, cultural, institutional and economic benefits that contribute to human wellbeing. In turn, each person’s relationship with the GBR is also influenced by a range of social, cultural, institutional and economic factors. Understanding these interactions is critical if we are to manage the GBR in a way that not only protects its natural values, but preserves and enhances its social values and the communities that have a relationship with it. These interactions (of the GBR and of people on the GBR) should inform the design of GBR-related governance and management systems at different scales. At the whole of GBR scale, managers need to understand wider societal interests in the GBR and socio-economic trends that influence whole of GBR outcomes. As a more local level example, managers are interested in how many people directly use or visit particular sites within the GBR; who these people are, where they go, what they do and why. The GBR’s human dimensions also have regional, GBR-wide, national and international aspects. National Environmental Science Program (NESP) Tropical Water Quality (TWQ) Hub Project 3.2.2 provides a methodology for assessing and monitoring the GBR’s human dimensions as a key mechanism to support governance and management of the GBR. It uses a conceptual framework to identify appropriate sets of indicators for characterising the desired state of the GBR’s human dimensions at the whole-of-GBR and regional scales. Some 25 indicator attributes that describe people’s relationship with the GBR can be grouped into five key attribute clusters. These include: (i) human aspirations, capacities and stewardship associated with the GBR; (ii) community vitality related to GBR outcomes; (iii) economic values related to GBR outcomes; (iv) culture and heritage related to the GBR; and (v) the health of governance systems affecting GBR outcomes. The framework is presented in full in Table 1 which also highlights major data gaps needed to inform this approach. Ongoing collection (regular and funded) of data related to these gaps is needed to fulfil the Reef 2050 Plan reporting of the GBR’s human dimensions. By populating the framework with available evidence (mostly secondary data sets) and regional discussions, we were able to demonstrate that all of the six natural resource management (NRM) regions within the GBR catchment scored moderately to well against all human dimension clusters, with conditions tending to decline with distance away from Brisbane for all clusters. Through the application of this framework, the project has already highlighted several significant and emerging implications for the Reef 2050 Plan review including: 1) The Australian and Queensland governments need to continue building partnerships with agricultural, tourism, fishing and recreational user communities and progress effective stewardship approaches. 2) Government agencies/researchers need to implement a stronger free, prior and informed consent-based approach in working with GBR Traditional Owners. 3) Government agencies and research institutions need to increase efforts to understand human use patterns across the GBR – how many people visit the GBR, where do people they go, how do they get there, why do they go. 4) Government agencies, in partnership with stakeholders, should progress system-wide approaches for continuous improvement within the wider system of governance affecting GBR outcomes. Efforts are needed to align policy and programs across a range of major policy areas that affect GBR outcomes, and significantly enhancing long term delivery systems. Improved connectivity is needed between environment, economic/regional development policy and social resilience programs of the Australian and Queensland governments and local governments. Effort needs to be better aligned across portfolios and levels of decision-making to address social and economic wellbeing and ecological health in the GBR. 5) A significant social license to operate needs to be built across the international and Australian community levels if government policies are to seek more urgent approaches to GBR protection and restoration in the face of climate change. 6) Government agencies and research institutions significantly need to increase efforts to protect historical maritime heritage in the GBR. 7) T o assist implementing the Reef 2050 Plan, the Australian and Queensland governments could more actively explore policies that increase the economic diversity and adaptive capacity of GBR-dependent regions - particularly north of Gladstone. This NESP-funded work was undertaken with collaboration and input from a GBR-wide (RIMReP) Human Dimensions Expert Group and six Regional Discussion Panels in the GBR catchment. As a result of this work, alignment of the human dimensions framework with Reef 2050 Plan targets, objectives and outcomes has revealed several gaps in the structure and implementation of the Reef 2050 Plan. It has also identified some human dimension attributes that are under-represented or overlooked in the Reef 2050 Plan. The consultation and expert- advisory processes used, and an associated literature review, also helped to shape the human dimensions framework