Inhibition of islet immunoreactivity by adiponectin is attenuated in human type 1 diabetes.

CONTEXT: Adiponectin is an adipocyte-derived cytokine with insulin-sensitizing and antiinflammatory properties. These dual actions have not previously been examined in the context of human disease. OBJECTIVES: Our objective was to examine the adiponectin axis in type 1 diabetes (T1D). T1D is an autoimmune inflammatory disease resulting from pancreatic ß-cell destruction, in which insulin resistance associates with progression to disease. DESIGN, PATIENTS, AND INTERVENTIONS: We measured circulating adiponectin and adiponectin receptor expression on blood-immune cells from 108 matched healthy, T1D, and type 2 diabetic subjects. We tested adiponectin effect on T cell proliferation to islet antigens and antigen-presenting function of monocyte-derived dendritic cells (mDCs). Lastly, we assessed the effect of a 3-week lifestyle intervention program on immune cell adiponectin receptor expression in 18 healthy subjects. RESULTS: Circulating concentrations of adiponectin were not affected by T1D. However, expression of adiponectin receptors on blood monocytes was markedly reduced and inversely associated with insulin resistance. Reduced adiponectin receptor expression resulted in increased T cell proliferation to islet-antigen presented by autologous mDCs. We demonstrated a critical role for adiponectin in down-regulating the costimulatory molecule CD86 on mDCs, and this function was impaired in T1D. We proceeded to show that lifestyle intervention increased adiponectin receptor but reduced CD86 expression on monocytes. CONCLUSIONS: These data indicate that T cells are released from the antiinflammatory effects of adiponectin in T1D and suggest a mechanism linking insulin resistance and islet immunity. Furthermore, we suggest that interventions that reduce insulin resistance could modulate the inflammatory process in T1D.

Mind the gap: Learners' perspectives on what they learn in communication compared to how they and others behave in the real world.

OBJECTIVE: To explore the lack of the learners' voice at previous international conferences on communication in healthcare. METHODS: A group of medical students and recently qualified junior doctors were invited to give the learner's perspective on how communication skills are taught and how they are implemented in 'real life', at a 90min symposium at the EACH International Conference on Communication in Healthcare, 4th September 2008, Oslo. RESULTS: We attempt to bridge the gap between learning communication skills formally in the medical classroom and actually implementing these in the real world between doctors and patients from a learners' perspective. In making this transition we highlight obvious weaknesses and potential pitfalls, whilst also drawing attention to the successful strategies used in our respective medical schools. Four key areas are discussed: (1) using simulated patients, (2) learning in the clinical setting, (3) barriers to utilizing communication skills, (4) future directions. We have drawn upon the learning experiences from both undergraduate and postgraduate environments in the UK, the USA and Norway. CONCLUSION: Our experiences differed between universities from the same country, which widened across continents. The differences between how we behave in the classroom and how we are with real patients when unobserved have been highlighted; and we have attempted to explain why trainees sometimes modify their behavior in medical assessments with standardized patients for examinations as opposed to how we would perform on wards or in general practice. The teaching of communication skills will continue to develop over the forthcoming years. PRACTICE IMPLICATIONS: Integrating communication skills into medical school curricula is essential. Identifying enthusiastic doctors who are effective communicators and have the initiative to help develop this is vital. It may be beneficial to train simulated patients to react to students in a variety of different ways to reflect the diversity of true patient responses. In addition, having a better understanding of the multidisciplinary roles and rapidly developing technology would facilitate not only communication between health professionals but would also help optimize patient care.