Diabetic Charcot neuroarthropathy: A threat to both limb and life.

Diabetic Charcot neuroarthropathy (DCN), first described in 1936, occurs in less than 1% of diabetic patients, but in those diabetic subjects with distal symmetrical polyneuropathy, the overall incidence increases to 30% and the risk is even greater in those with type 1 diabetes. Factors that precipitate DCN are trauma, ischaemia due to arterio-venous shunting, increased osteoclastic activity and inflammation. DCN usually presents with a painless swollen foot and/or ankle which is 'hot to the touch'. These clinical findings are soon followed by characteristic magnetic resonance imaging (MRI) abnormalities and later X-ray changes. The joints that are most typically involved in chronological order are the tarsometatarsals followed by the naviculocuniform, sub-tarsal, talonavicular and metatarsal and tarsophalangeal. The cornerstone of therapy is prolonged (3-12 months) offloading with immobilization. Bisphosphonates may possibly accelerate recovery, whereas other unproven possible therapies include rhPTH, 1-34, calcitonin and methylprednisolone, which are not only ineffective but in some cases may also prolong the time to healing. Denosumab is potentially an efficacious, if unproven, therapy to accelerate healing. The risk of amputation is high and increases in the presence of a foot ulcer. DCN is associated with manifestations of autonomic neuropathy, including cardiac denervation, so that the risks of a cardiac event and heart failure are increased with DCN. Mortality is also increased with DCN, especially in the presence of a foot ulcer. To avoid the recurrence of DCN and especially to lower the risk of the recurrence of a foot ulcer recurrence reconstructive, surgery may be needed.

Exogenous Insulin Antibody Syndrome (EIAS) Presenting in an Elderly, Long-Term Patient with Type 1 Diabetes Mellitus that Resolved with Low-Cost Outpatient Therapy with Mycophenolate Mofetil and Regular Insulin by Pump.

Exogenous insulin antibody syndrome (EIAS) has until recently been a rarely described complication of exogenous insulin therapy. EIAS results not only in hyperglycemia, but also in hypoglycemia and occasionally in ketoacidosis (DKA). The incidence of EIAS is increasing probably due to an overall increase in autoimmunity associated with the coronavirus disease 2019 (Covid-19) epidemic resulting in increasing binding of insulin by antibodies. Herein, we describe a case of EIAS occurring in an elderly patient with longstanding type 1 diabetes mellitus (T1DM) who had progressive loss of glycemic control. It responded positively, as we have previously described, to oral mycophenolate mofetil and the use of soluble regular insulin delivered by continuous subcutaneous insulin infusion (CSII). Therefore, EIAS is an increasingly frequent cause of hyperglycemia with and without DKA, and hypoglycemia in subjects with T1DM. Once diagnosed, they can be treated with mycophenolate mofetil and soluble insulin in an outpatient setting, which will decrease the rate of hospitalization and lower the expense of therapy.

The potential for improved outcomes in the prevention and therapy of diabetic kidney disease through 'stacking' of drugs from different classes.

Aggressive therapy of diabetic kidney disease (DKD) can not only slow the progression of DKD to renal failure but, if utilized at an early enough stage of DKD, can also stabilize and/or reverse the decline in renal function. The currently recognized standard of therapy for DKD is blockade of the renin-angiotensin system with angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs). However, unless utilized at a very early stage, monotherapy with these drugs in DKD will only prevent or slow the progression of DKD and will neither stabilize nor reverse the progression of DKD to renal decompensation. Recently, the addition of a sodium-glucose cotransporter-2 inhibitor and/or a mineralocorticoid receptor blocker to ACE inhibitors or ARBs has been clearly shown to further decelerate the decline in renal function. The use of glucagon-like peptide-1 (GLP-1) agonists shown promise in decelerating the progression of DKD. Other drugs that may aid in the deceleration the progression of DKD are dipeptidyl peptidase-4 inhibitors, pentoxifylline, statins, and vasodilating beta blockers. Therefore, aggressive therapy with combinations of these drugs (stacking) should improve the preservation of renal function in DKD.

Extraction of volatile organic compounds liberated upon filament extrusion by 3D pen and its comparison with a desktop 3D printer using solid-phase microextraction fiber and Arrow.

Desktop 3D printers that operate by the fused deposition modeling (FDM) mechanism are known to release numerous hazardous volatile organic compounds (VOCs) during printing, including some with potential carcinogenic effects. Operating in a similar manner to FDM 3D printers, 3D pens have gained popularity recently from their ability to allow users to effortlessly draw in the air or create various 3D printed shapes while handling the device like a pen. In contrast to numerous modern 3D printers, 3D pens lack their own ventilation systems and are often used in settings with minimum airflow. Their operation makes users more vulnerable to VOC emissions, as the released VOCs are likely to be in the breathing zone. Consequently, monitoring VOCs released during the use of 3D pens is crucial. In this study, VOCs liberated while extruding acrylonitrile butadiene styrene (ABS) filaments from a 3D pen were measured by solid-phase microextraction (SPME) combined with gas chromatography/mass spectrometry (GC/MS). SPME was investigated using the traditional fiber and Arrow geometries with the DVB/Carbon WR/PDMS sorbent while four different brands of ABS filaments-Amazon Basics, Gizmodork, Mynt 3D, and Novamaker-were used with the 3D pen. Heatmap analysis showed differentiation among these brands based on the liberated VOCs. The nozzle temperature and printing speed were found to affect the number and amount of released VOCs. This study goes a step further and presents for the first time a comparison between 3D pen and a desktop 3D printer based on liberated VOCs. Interestingly, the findings reveal that the 3D pen releases a greater number and amount of VOCs compared to the printer. The amounts of liberated VOCs, as indicated by the corresponding chromatographic peak areas, were found to be 1.4 to 62.6 times higher for the 3D pen compared to the 3D printer when using SPME Arrow.

Polymeric ionic liquid sorbent coatings in thin film microextraction: Insight into sorbent selectivity for pesticides and cannabinoids.

Polymeric ionic liquid (PIL) sorbent coatings consisting of polymerizable cations and anions were employed as sorbent coatings in thin film microextraction (TFME) for the extraction of pesticides and cannabinoids. The blades consisted of a thin film of PIL sorbents chemically bonded to vinyltrimethoxysilane-functionalized nitinol sheets. The imidazolium- or ammonium-based PIL sorbents contained aromatic benzyl moieties as well as polar hydroxyl groups or aliphatic functional groups within the chemical structure of the IL monomer. The chemical structure of the IL crosslinkers of the PILs were kept constant across each sorbent, except for the anion, which consisted of either bis[(trifluoromethyl)sulfonyl]imide ([NTf2-]), p-styrenesulfonate ([SS-]), or 3-sulfopropyl acrylate ([SPA-]). Temperature, salt content, and methanol content were optimized as extraction conditions to maximize pesticide-cannabinoid selectivity using Doehlert design of experiments (DOE). Effects of these three factors on selectivity and extraction efficiency are discussed. The optimal extraction conditions consisting of sample temperature (31°C), sodium chloride (30% w/v), and methanol content (0.25% v/v) are compared to initial sorbent screening conditions at a sample temperature of 40°C, 15% (w/v) sodium chloride, and 2.5% (v/v) methanol content. PIL sorbent swelling behavior at different salt and methanol content conditions and its effect on extraction efficiency are hypothesized. Selectivity factors for the sorbents indicated that aromatic moieties within the IL monomer may enhance pesticide-cannabinoid selectivity under optimized conditions, but the extraction efficiency of pesticides that are known to coelute with cannabinoids in the chromatographic separation may be enhanced by employing sorbent coatings with [SPA-] anions.

In praise of pioglitazone: An economically efficacious therapy for type 2 diabetes and other manifestations of the metabolic syndrome.

Pioglitazone improves glycaemic control, not only by lowering insulin resistance, but also by improving beta cell function. Because of the improved beta cell function the glycaemic control that occurs with pioglitazone is prolonged. Pioglitazone has positive effects not only on cardiac risk factors and surrogate measures of cardiovascular disease, it also lowers the incidence of cardiac events in patients with diabetes. The recurrence of transient ischaemic attack and ischaemic stroke is also reduced in non-diabetic, insulin-resistant subjects. Utilized at preclinical stages (but not later) of heart failure, pioglitazone improves diastolic function and avoids progression to heart failure. Pioglitazone, through suppression of atrial remodelling, also decreases the incidence of atrial fibrillation. The manifestations of diseases associated with insulin resistance (non-alcoholic steatohepatitis and polycystic ovary disease) are also improved with pioglitazone. Pioglitazone may possibly improve psoriasis and other dermopathies. Pioglitazone is therefore an inexpensive and efficacious drug for the insulin-resistant subject with diabetes that is underutilized because of biases that have evolved from the toxicities of other thiazolidinediones.

Controlling the surface silanol density in capillary columns and planar silicon via the self-limiting, gas-phase deposition of tris(dimethylamino)methylsilane, and quantification of surface silanols after silanization by low energy ion scattering.

Surface silanols (Si-OH) play a vital role on fused silica surfaces in chromatography. Here, we used an atmospheric-pressure, gas-phase reactor to modify the inner surface of a gas chromatography, fused silica capillary column (0.53 mm ID) with a small, reactive silane (tris(dimethylamino)methylsilane, TDMAMS). The deposition of TDMAMS on planar witness samples around the capillary was confirmed with X-ray photoelectron spectroscopy (XPS), ex situ spectroscopic ellipsometry (SE), and wetting. The number of surface silanols on unmodified and TDMAMS-modified native oxide-terminated silicon were quantified by tagging with dimethylzinc (DMZ) via atomic layer deposition (ALD) and counting the resulting zinc atoms with high sensitivity-low energy ion scattering (HS-LEIS). A bare, clean native oxide - terminated silicon wafer has 3.66 OH/nm2, which agrees with density functional theory (DFT) calculations from the literature. After TDMAMS modification of native oxide-terminated silicon, the number of surface silanols decreases by a factor of ca. 10 (to 0.31 OH/nm2). Intermediate surface testing (IST) was used to characterize the surface activities of functionalized capillaries. It suggested a significant deactivation/passivation of the capillary with some surface silanols remaining; the modified capillary shows significant deactivation compared to the native/unmodified fused silica tubing. We believe that this methodology for determining the number of residual silanols on silanized fused silica will be enabling for chromatography.

Area-Selective Atomic Layer Deposition of ZnO on Si\SiO2 Modified with Tris(dimethylamino)methylsilane.

Delayed atomic layer deposition (ALD) of ZnO, i.e., area selective (AS)-ALD, was successfully achieved on silicon wafers (Si\SiO2) terminated with tris(dimethylamino)methylsilane (TDMAMS). This resist molecule was deposited in a home-built, near-atmospheric pressure, flow-through, gas-phase reactor. TDMAMS had previously been shown to react with Si\SiO2 in a single cycle/reaction and to drastically reduce the number of silanols that remain at the surface. ZnO was deposited in a commercial ALD system using dimethylzinc (DMZ) as the zinc precursor and H2O as the coreactant. Deposition of TDMAMS was confirmed by spectroscopic ellipsometry (SE), X-ray photoelectron spectroscopy (XPS), and wetting. ALD of ZnO, including its selectivity on TDMAMS-terminated Si\SiO2 (Si\SiO2\TDMAMS), was confirmed by in situ multi-wavelength ellipsometry, ex situ SE, XPS, and/or high-sensitivity/low-energy ion scattering (HS-LEIS). The thermal stability of the TDMAMS resist layer, which is an important parameter for AS-ALD, was investigated by heating Si\SiO2\TDMAMS in air and nitrogen at 330 °C. ALD of ZnO takes place more readily on Si\SiO2\TDMAMS heated in the air than in N2, suggesting greater damage to the surface heated in the air. To better understand the in situ ALD of ZnO on Si\SiO2\TDMAMS and modified (thermally stressed) forms of it, the ellipsometry results were plotted as the normalized growth per cycle. Even one short pulse of TDMAMS effectively passivates Si\SiO2. TDMAMS can be a useful, small-molecule inhibitor of ALD of ZnO on Si\SiO2 surfaces.

Understanding the influence of polymeric ionic liquid sorbent coating substituents on cannabinoid and pesticide affinity in solid-phase microextraction.

To understand factors that drive pesticide-cannabinoid selectivity in solid-phase microextraction (SPME), eight new polymeric ionic liquid (PIL) sorbent coatings were designed and compared to four previously reported PIL sorbent coatings for the extraction of pesticides. The four PIL sorbent coatings consisted of either vinylimidazolium or vinylbenzylimidazolium ILs with long alkyl chain substituents (i.e., -C8H17 or -C12H25) and bis[(trifluoromethyl)sulfonyl]imide ([NTf2-]) anions, from which the eight new PIL sorbent coatings were adapted. Modifications to the chemical structure of IL monomers and crosslinkers included incorporation of polymerizable p-styrenesulfonate or 3-sulfopropyl acrylate anions, the addition of aromatic moieties, and/or the addition of polar functional groups (i.e., -OH or -O- groups). A total of ten commonly regulated pesticides and six cannabinoids were examined in this study. The effect of salt on the solubility of pesticides and cannabinoids in aqueous solutions was assessed by determining their extraction efficiencies in the presence of varied methanol content. Differences in their solubilities appear to play a dominant role in enhancing pesticide-cannabinoid selectivity. The selectivity, represented as the ratio of pesticide total peak areas to cannabinoid total peak areas, also exhibited a moderate correlation to the affinity of the sorbent coatings towards both the pesticides and the cannabinoids. A positive correlation was observed for the pesticides and a negative correlation was observed for the cannabinoids, suggesting that selectivity was driven by more than the presence of salt in the samples. The sorbent coatings' affinity towards each class of analytes were examined to determine specific interactions that might influence selectivity. The two main structural modifications increasing pesticide-cannabinoid selectivity included the absence of aromatic moieties and the addition of hydrogen bond donor functional groups. Extractions of simple aromatic molecules as probes were performed under similar extraction conditions as the cannabinoids and confirmed the influence of hydrogen bonding interactions on sorbent coating affinity.

Management of the 'wicked' combination of heart failure and chronic kidney disease in the patient with diabetes.

Patients with type 2 diabetes are at an increased risk of developing heart failure and chronic kidney disease. The presence of these co-morbidities substantially increases the risk of morbidity as well as mortality in patients with diabetes. The clinical focus has historically centred around reducing the risk of cardiovascular disease by targeting hyperglycaemia, hyperlipidaemia and hypertension. Nonetheless, patients with type 2 diabetes who have well-controlled blood glucose, blood pressure and lipid levels may still go on to develop heart failure, kidney disease or both. Major diabetes and cardiovascular societies are now recommending the use of treatments such as sodium-glucose co-transporter-2 inhibitors and non-steroidal mineralocorticoid receptor antagonists, in addition to currently recommended therapies, to promote cardiorenal protection through alternative pathways as early as possible in individuals with diabetes and cardiorenal manifestations. This review examines the most recent recommendations for managing the risk of cardiorenal progression in patients with type 2 diabetes.

Heart failure and diabetes: Clinical significance and epidemiology of this two-way association.

People with type 2 diabetes (T2DM) and those with prediabetes have an increased risk of heart failure (HF). Longer duration of T2DM correlates with a greater risk of HF, but HF is also seen in patients with recent-onset diabetes. Insulin resistance is more likely to be present in patients with HF. The risk of HF persists even in the face of standard-of-care preventive treatments for atherosclerotic cardiovascular (CV) disease. HF is commonly the presenting symptom of CV disease in people with diabetes and is the most expensive complication of diabetes because of the high cost of hospitalizations. Recently hospitalization for HF has been included in CV outcome trials (CVOTs), including for medications that are used to treat T2DM, which has led to new therapies for all HF patients. In addition, these CVOTs have shown that many drugs used in the therapy of diabetes are either neutral or detrimental in the HF patient and should be used with caution in patients with existing HF or those at high risk of HF. Most recently, sodium-glucose cotransporter-2 receptor blockers have shown efficacy in both HF with reduced ejection fraction (EF) and HF with preserved EF. The only other oral or injectable diabetes agent shown to improve outcomes in both is metformin.

Monitoring the liberation of volatile organic compounds during fused deposition modeling three dimensional printing using solid-phase microextraction coupled to gas chromatography/mass spectrometry.

Three-dimensional (3D) printers have gained tremendous popularity and are being widely used in offices, laboratories, and private homes. Fused deposition modeling (FDM) is among the most commonly used mechanisms by desktop 3D printers in indoor settings and relies on the extrusion and deposition of heated thermoplastic filaments, resulting in the liberation of volatile organic compounds (VOCs). With the growing use of 3D printers, concerns regarding human health have risen as the exposure to VOCs may cause adverse health effects. Therefore, it is important to monitor VOC liberation during printing and to correlate it to filament composition. In this study, VOCs liberated with a desktop printer were measured by solid-phase microextraction (SPME) combined with gas chromatography/mass spectrometry (GC/MS). SPME fibers featuring sorbent coatings of varied polarity were chosen for the extraction of VOCs liberated from acrylonitrile butadiene styrene (ABS), tough polylactic acid, and copolyester+ (CPE+) filaments. It was found that for all three filaments tested, longer print times resulted in a greater number of extracted VOCs. The ABS filament liberated the most VOCs while the CPE+ filaments liberated the fewest VOCs. Through the use of hierarchical cluster analysis and principal component analysis, filaments as well as fibers could be differentiated based on the liberated VOCs. This study demonstrates that SPME is a promising tool to sample and extract VOCs liberated during 3D printing under non-equilibrium conditions and can be used to aid in tentative identification of the VOCs when coupled to gas chromatography-mass spectrometry.

Detecting and treating the protean manifestations of diabetic autonomic neuropathy.

The manifestations of diabetic autonomic neuropathy (DAN) are protean and clinically involve multiple systems, including the cardiovascular system, the gastrointestinal system, the genitourinary system as well as the sweat glands (sudomotor dysfunction) and the gallbladder. In addition, cardiac autonomic neuropathy (CAN) is associated with a correctible inability to appreciate and correct hypoglycaemia. While not a clinical problem, pupillary involvement should be the clue and the catalyst to investigate for other manifestations of DAN. This review outlines a practical approach to detecting and investigating the manifestations of DAN. Of particular importance is early detection of cardiovascular involvement where prompt therapy through glycaemic control can decrease the severity of CAN and decelerate the frequency and severity of retinopathy and nephropathy in addition to decreasing cardiovascular events and mortality. CAN also plays a role in accelerating other diabetic complications such as acute ischaemic stroke, heart failure, medial artery calcinosis, foot ulcers, peripheral artery disease and Charcot joints. Many therapies of DAN are available, which should not only decrease morbidity and mortality from DAN, but also improve the patient's quality of life. However, the therapies available are largely symptomatic.

Leveraging multi-mode microextraction and liquid chromatography stationary phases for quantitative analysis of neurotoxin ß-N-methylamino-L-alanine and other non-proteinogenic amino acids.

Effective quantitative analysis of BMAA (ß-N-methylamino-L-alanine) and its isomers without the need for derivatization has always been an analytical challenge due to their poor retention and separation on various liquid chromatography stationary phases. Previous studies that utilized conventional hydrophilic interaction chromatography (HILIC) demonstrate false negatives compared to reverse-phase workflows with derivatization. This work evaluates the chromatographic behavior of BMAA and its isomers, in their underivatized forms, on selected stationary phases, in particular fluorophenyl-based columns, to attain effective retention and separation. Detection and quantification were achieved with an ion-trap mass spectrometer. Extraction and preconcentration were achieved via solid phase microextraction (SPME) by assessing the effectiveness of multiple extraction phases, including hydrophilic-lipophilic balanced (HLB) and mixed-mode (MM). A MM extraction phase consisting of C8 and benzene sulfonic acid moieties provided ideal extraction performance for BMAA and its isomers (2,4-diaminobutyric acid, DABA; N-(2-aminoethyl) glycine, AEG). Chromatographic separation was achieved within 8 min on a fluorophenyl stationary phase, ensuring high throughput without derivatization, and showing exceptional improvement from conventional HILIC methods. Limits of quantification in water for BMAA and AEG were 2.5 µg L-1 and DABA was 5 µg L-1, with linear dynamic ranges from 2.5 µg L-1 - 200 µg L-1 for BMAA and AEG and 5 µg L-1 - 200 µg L-1 for DABA.

Combine and Conquer: With Type 2 Diabetes Polypharmacy Is Essential Not Only to Achieve Glycemic Control but Also to Treat the Comorbidities and Stabilize or Slow the Advancement of Diabetic Nephropathy.

The concept of polypharmacy in the type 2 diabetic patient is both historic and redundant. A combination of three or more medications usually at doses which are less than those utilized for monotherapy is efficacious not only in the therapy of hyperglycemia but also in the therapy of the comorbidities of hypertension and hyperlipidemia. In addition, multiple medications are now accepted as being necessary to reduce albuminuria and decelerate the decline in renal function in the patient with diabetic nephropathy.

Diabetic Mononeuropathies and Diabetic Amyotrophy.

This brief review describes the etiology, pathophysiology, clinical features, therapy and prognosis of the diabetic mononeuropathies and diabetic amyotrophy and neuropathic cachexia. Mononeuropathies include cranial neuropathies, of which the oculomotor nerve is most commonly affected, and are thought to be due to microvascular occlusion. Peripherally, entrapment neuropathies occur in both the upper and lower limbs and are due to compression of an already damaged nerve in anatomically restricted channels. Diabetic radiculopathies occur in the dermatones of the thorax and abdomen, mimicking intraabdominal or intrathoracic pathology. I also describe the features of the rare but very distinctive diabetic amyotrophy and neuropathic cachexia. Overall, the prognosis from these conditions is excellent with residual pain or muscle weakness being rare with the exception of diabetic amyotrophy where the prognosis is dependent upon cooperation with intensive rehabilitation. Therapies include "watchful waiting," physical therapy and rarely surgical intervention, which may be urgently needed for nerve decompression and reversal of motor defects.