The clinical management of hyperglycemia in pregnancy complicated by maturity-onset diabetes of the young.

OBJECTIVE: Women with maturity-onset diabetes of the young (MODY) are often first identified and diagnosed with diabetes during pregnancy. Genetics and hyperglycemia play an important role in determining fetal size in MODY pregnancies. The principal objective of the current study is to determine the outcomes and clinical management of hyperglycemia in pregnancies complicated by glucokinase gene (GCK) and hepatocyte nuclear factor (HNF)-1α MODY mutations. STUDY DESIGN: A retrospective chart review of 37 women with a GCK/HNF-1α mutation was conducted. Data on variables such as birthweight, mode of delivery, and the treatment of hyperglycemia were available on 89 pregnancies. RESULTS: The birthweight in unaffected GCK offspring was significantly higher than in the affected GCK offspring (4.8 [4.1-5.2] kg vs 3.2 [3.1-3.7] kg; P = .01). Seven-point home blood glucose monitoring over a 7-day period in each trimester demonstrated higher fasting and postprandial glycemic excursions in the first trimester of GCK pregnancies when compared to HNF-1α pregnancies (fasting 104 [90-115] mg/dL vs 84 [77-88] mg/dL; P = .01 and postprandial 154 [135-196] mg/dL vs 111 [100-131] mg/dL; P = .04) despite insulin treatment. There was a higher percentage of miscarriages in the GCK group when compared to the HNF-1α MODY group (33.3% vs 14%; P = .07), which was similar to the background population. Insulin initiated at an early gestation appeared to lower the incidence of macrosomia in GCK unaffected offspring. CONCLUSION: Hyperglycemia in HNF-1α pregnancies is easily managed with current insulin protocols; in contrast, glycemic excursions are difficult to manage in GCK pregnancies. There was an increased percentage of miscarriages in GCK pregnancies highlighting the importance of a diagnosis of GCK-MODY in women prior to conception and the necessity for preconception care.

The experiences, motivations, and opinions of New Zealand's live liver donors.

AIM: To explore the motivations and experiences of New Zealand's live liver donors, and their opinions on New Zealand's current organ donation system. METHOD: An anonymous questionnaire was sent to all 45 of New Zealand's live liver donors in November 2012. RESULT: 21 responses were collated with an even gender split. Half of the participants were parents of the recipient. Despite the risks of surgery and associated post-surgical pain, all participants were satisfied by how the transplant went for the recipient and for themselves. 90% thought people should save lives if they can, with 18 (86%) disagreeing with New Zealand's current method of allowing family members to veto the deceased person's wishes on organ donation (on their driver's license). 95% thought that education was important in encouraging people to donate. CONCLUSION: This unique and informed group have experienced both what it means to have a loved one waiting for a transplant and how it feels to be an organ donor. If New Zealand is serious about wanting to increase deceased organ donation rates, we should consider the experiences such as those who have undergone live donation.

Insights into thermoregulation: a clinico-radiological description of Shapiro syndrome.

Shapiro syndrome is a rare entity, comprising a triad of recurrent hypothermia, hyperhidrosis and congenital agenesis of the corpus callosum. Fewer than 50 cases have been described, almost invariably in patients presenting in childhood or early adulthood. We present a case of an 80 year old woman presenting with recurrent bouts of shivering, sweating and profound malaise, who sought medical attention because the frequency and severity of attacks worsened in her later years. MRI Brain demonstrated agenesis of the corpus callosum; a rigorous work-up excluded other causes for her symptomatology. The intricate interplay of neuronal networks involved in thermoregulation remains to be fully elucidated and as such, little is known about the pathophysiological mechanisms underlying the clinical manifestations of Shapiro syndrome. We present novel data from FDG-PET imaging of our patient, demonstrating hypermetabolism in a number of brainstem and cerebellar regions during the symptomatic phase. These findings imply that aberrant thermoregulation in Shapiro syndrome involves a number of structures remote from the callosal region. We also present neuropsychometric findings in our patient, of which there have been no reports to date. We postulate that the ageing brain may be more susceptible to the paroxysmal neurochemical fluxes implicated in the syndrome.

Manganese neurotoxicity and the role of reactive oxygen species.

Manganese (Mn) is an essential dietary nutrient, but an excess or accumulation can be toxic. Disease states, such as manganism, are associated with overexposure or accumulation of Mn and are due to the production of reactive oxygen species, free radicals, and toxic metabolites; alteration of mitochondrial function and ATP production; and depletion of cellular antioxidant defense mechanisms. This review focuses on all of the preceding mechanisms and the scientific studies that support them as well as providing an overview of the absorption, distribution, and excretion of Mn and the stability and transport of Mn compounds in the body.

Resistance exercise but not aerobic exercise lowers remnant-like lipoprotein particle cholesterol in type 2 diabetes: a randomized controlled trial.

The comparative effects of aerobic and resistance exercise on triglyceride-rich lipoproteins including remnant lipoproteins are controversial. This study examined exercise effect on remnant-like lipoprotein particle cholesterol (RLP-C) in type 2 diabetes. Participants were randomized to control (Control), aerobic (Aerobic), resistance (Resistance), or both (Combined) exercise groups. Baseline and 6-month fasting RLP-C and apolipoprotein B48 concentrations were measured. Data analysis was on an intention-to-treat basis. At 6 months, RLP-C was lower in all groups; ΔRLP-C mg/dl, (95% confidence interval), Control -3.91, (-6.21 to -1.6), p=0.001; Aerobic -3.89, (-6.41 to -1.36), p=0.003, Resistance -7.52, (-9.89 to -5.15), p=0.0001, Combined -7.50, (-9.87 to -5.13), p=0.0001. Total triglycerides were significantly lower in Resistance and Combined groups only; -17.7mg/dl (-32.8 to -2.7), p=0.02 and -27.5 (-42.5 to -11.5), p=0.001, respectively. Inter-group comparisons showed no difference in RLP-C change between Aerobic and Control and a significant difference in RLP-C change only where groups incorporating resistance exercise were compared with those without. There was no significant difference in RLP-C change between Resistance and Combined. Inter-group comparisons of total triglycerides change were significant only between Combined and Control. Changes in apolipoprotein B48 were not significant in inter-group comparisons. In conclusion, our data indicate that resistance exercise training, not aerobic, lowers RLP-C in type 2 diabetes. This effect was not revealed by changes in total triglycerides and apolipoprotein B48. The discordance between changes in RLP-C and apolipoprotein B48 in response to resistance exercise may indicate (a) a decrease in VLDL remnant and not chylomicron remnant particle number and/or (b) a depletion of cholesterol in chylomicron and/or VLDL remnants.

An analysis of the effects of Mn2+ on oxidative phosphorylation in liver, brain, and heart mitochondria using state 3 oxidation rate assays.

Manganese (Mn) toxicity is partially mediated by reduced ATP production. We have used oxidation rate assays--a measure of ATP production--under rapid phosphorylation conditions to explore sites of Mn(2+) inhibition of ATP production in isolated liver, brain, and heart mitochondria. This approach has several advantages. First, the target tissue for Mn toxicity in the basal ganglia is energetically active and should be studied under rapid phosphorylation conditions. Second, Mn may inhibit metabolic steps which do not affect ATP production rate. This approach allows identification of inhibitions that decrease this rate. Third, mitochondria from different tissues contain different amounts of the components of the metabolic pathways potentially resulting in different patterns of ATP inhibition. Our results indicate that Mn(2+) inhibits ATP production with very different patterns in liver, brain, and heart mitochondria. The primary Mn(2+) inhibition site in liver and heart mitochondria, but not in brain mitochondria, is the F1F0 ATP synthase. In mitochondria fueled by either succinate or glutamate+malate, ATP production is much more strongly inhibited in brain than in liver or heart mitochondria; moreover, Mn(2+) inhibits two independent sites in brain mitochondria. The primary site of Mn-induced inhibition of ATP production in brain mitochondria when succinate is substrate is either fumarase or complex II, while the likely site of the primary inhibition when glutamate plus malate are the substrates is either the glutamate/aspartate exchanger or aspartate aminotransferase.

Thyroid-stimulating hormone stimulates lipolysis in adipocytes in culture and raises serum free fatty acid levels in vivo.

Thyroid-stimulating hormone (TSH) stimulates adipocyte lipolysis, but signal transduction pathways activated by TSH for this response have not been directly studied. Using differentiated 3T3-L1 adipocytes as well as primary human adipocytes, we characterized the lipolytic action of TSH with dose-response and time-course studies, and compared it with isoproterenol. Thyroid-stimulating hormone stimulated phosphorylation of perilipin and hormone-sensitive lipase (HSL). Inhibition of protein kinase A with H89 blocked TSH-stimulated lipolysis as well as phosphorylation of perilipin and HSL. Thyroid-stimulating hormone stimulated lipolysis in vivo, as indicated by an elevation in serum free fatty acid (FFA) levels after recombinant human TSH administration to thyroidectomized patients (42% increase, n = 19, P < .05). For patients with a body mass index less than 30 kg/m(2), the TSH-induced increase in serum FFA levels was 53% (n = 11, P < .05), whereas levels in patients with a body mass index of at least 30 kg/m(2) (n = 8) did not change after TSH treatment. In summary, TSH stimulates lipolysis and phosphorylation of perilipin and HSL in a protein kinase A-dependent manner in differentiated adipocytes in culture and raises serum FFA levels in vivo.

Proposing a causal link between thyroid hormone resistance and primary autoimmune hypothyroidism.

Resistance to thyroid hormone (RTH) is a rare, inherited condition. It is characterised by raised circulating fT4 and TSH levels. The literature contains a number of descriptions of the finding of thyroid autoantibodies in patients with RTH. Until now, this has been attributed to the coincidental development of primary autoimmune thyroiditis as a second unrelated pathology. Our hypothesis is that the chronic TSH elevation in RTH stimulates lymphocytes to produce the pro-inflammatory cytokine TNF-alpha. TNF-alpha, in turn mediates thyroid cell destruction by binding to its receptors on thyrocytes, or indirectly by potentiating antibody formation or cytotoxic T lymphocyte production.

Speciation of manganese in cells and mitochondria: a search for the proximal cause of manganese neurotoxicity.

Recent studies of speciation of manganese (Mn) in brain mitochondria, neuron-like cells, and astrocytes are reviewed. No evidence is found for oxidation of Mn(2+) complexes to a Mn(3+) complex. The only evidence for any Mn(3+) complex is found in a spectrum essentially identical to that of mitochondrial manganese superoxide dismutase (MnSOD). While this does not prove that no Mn(3+) is produced in these tissues by oxidation of Mn(2+), it does suggest that formation of an active Mn(3+) complex by oxidation of Mn(2+) probably does not play as important a role in Mn toxicity as has been suggested earlier. Since these results suggest that we should look elsewhere for the proximal causes of Mn neurotoxicity, we consider the possibilities that Mn(3+) may be transported into the cell via transferrin and that Mn(2+) may inhibit Ca(2+)-activation and control of the rate of ATP production by oxidative phosphorylation.

Determination of the oxidation states of manganese in brain, liver, and heart mitochondria.

Excess brain manganese can produce toxicity with symptoms that resemble those of Parkinsonism and causes that remain elusive. Manganese accumulates in mitochondria, a major source of superoxide, which can oxidize Mn2+ to the powerful oxidizing agent Mn3+. Oxidation of important cell components by Mn3+ has been suggested as a cause of the toxic effects of manganese. Determining the oxidation states of intramitochondrial manganese could help to identify the dominant mechanism of manganese toxicity. Using X-ray absorbance near edge structure (XANES) spectroscopy, we have characterized the oxidation state of manganese in mitochondria isolated from brain, liver, and heart over concentrations ranging from physiological to pathological. Results showed that (i) spectra from different model manganese complexes of the same oxidation state were similar to each other and different from those of other oxidation states and that the position of the absorption edge increases with oxidation state; (ii) spectra from intramitochondrial manganese in isolated brain, heart and liver mitochondria were virtually identical; and (iii) under these conditions intramitochondrial manganese exists primarily as a combination of Mn2+ complexes. No evidence for Mn3+ was detected in samples containing more than endogenous manganese levels, even after incubation under conditions promoting reactive oxygen species (ROS) production. While the presence of Mn3+ complexes cannot be proven in the spectrum of endogenous mitochondrial manganese, the shape of this spectrum could suggest the presence of Mn3+ near the limit of detection, probably as MnSOD.

XANES spectroscopy: a promising tool for toxicology: a tutorial.

X-ray absorption near edge structure (XANES) spectroscopy can provide information on the oxidation state of metal ions within a biological sample and also the complexes in which it is found. This type of information could be of great use to toxicologists in understanding the mechanism of action of many toxic agents. The prospect of using a sophisticated physical technique such as XANES may be somewhat intimidating for those without a strong physical background. Here, we explain the concepts necessary to understand XANES spectroscopy at a level that can be easily understood by biological scientists without a strong physics background and describe useful sample preparation and data analysis techniques which can be adapted for a variety of applications. Examples are taken from an ongoing study of manganese in brain mitochondria and neuron-like cells.