Retention of Virus Versus Surrogate, by Ultrafiltration in Seawater: Case Study of Norovirus Versus Tulane.

In the field of chemical engineering and water treatment, the study of viruses, included surrogates, is well documented. Often, surrogates are used to study viruses and their behavior because they can be produced in larger quantities in safer conditions and are easier to handle. In fact, surrogates allow studying microorganisms which are non-infectious to humans but share some properties similar to pathogenic viruses: structure, composition, morphology, and size. Human noroviruses, recognized as the leading cause of epidemics and sporadic cases of gastroenteritis across all age groups, may be mimicked by the Tulane virus. The objectives of this work were to study (i) the ultrafiltration of Tulane virus and norovirus to validate that Tulane virus can be used as a surrogate for norovirus in water treatment process and (ii) the retention of norovirus and the surrogate as a function of water quality to better understand the use of the latter pathogenic viruses. Ultrafiltration tests showed significant logarithmic reduction values (LRV) in viral RNA: around 2.5 for global LRV (i.e., based on the initial and permeate average concentrations) and between 2 and 6 for average LRV (i.e., retention rate considering the increase of viral concentration in the retentate), both for norovirus and the surrogate Tulane virus. Higher reduction rates (from 2 to 6 log genome copies) are obtained for higher initial concentrations (from 101 to 107 genome copies per mL) due to virus aggregation in membrane lumen. Tulane virus appears to be a good surrogate for norovirus retention by membrane processes.

Microplastics in different water samples (seawater, freshwater, and wastewater): Removal efficiency of membrane treatment processes.

The distribution and fate of microplastics in different water sources and their treatment plants (seawater, three municipal wastewaters, a pharmaceutical factory wastewater, and three drinking waters) in France were studied. Currently, research in this field is still under exploration since almost no relevant standards or policies have been introduced for the detection, the removal, or the discharge of microplastics. This study used an improved quantitative and qualitative analytical methodology for microplastic detection by µ-FTIR carried out with siMPle analytical software. By investigation, wastewater was determined to contain the most abundant microplastics in quantity (4,203-42,000 MP·L-1), then followed by surface water/groundwater (153-19,836 MP·L-1) and seawater (around 420 MP·L-1). Polyethylene was the dominant material in almost all water types followed by polypropylene, polystyrene, and polyethylene terephthalate. Almost all treatment technologies could remove microplastics whatever the feed water types and concentration of microplastics, though some treatment processes or transport pipes could cause additional contamination from microplastics. The four WWTPs, three DWTPs, and SWTP in France provided, respectively, 87.8-99.8%, 82.3-99.9%, 69.0-96.0% removal/retention of MPs in quantity, and provided 97.3-100%, 91.9-99.9%, 92.2-98.1% removal/retention of MPs in surface area. Moreover, ultrafiltration was confirmed to be an effective technology for microplastic retention and control of dimensions of microplastics in smaller ranges both in field-scale and lab-scale experiments. The 200 kDa ultrafiltration membrane could retain 70-100% and 80-100% of microplastics in quantity and in surface area, respectively.

Microplastics in different water samples (seawater, freshwater, and wastewater): Methodology approach for characterization using micro-FTIR spectroscopy.

Microplastics of millimeter dimensions have been widely investigated in environmental compartments and today, studies are mainly focused on particles of smaller dimensions (< 500 µm). However, as there are no relevant standards or policies for the preparation and analysis of complex water samples containing such particles, the results may be questionable. Therefore, a methodological approach for 10 µm to 500 µm microplastic analysis was developed using µ-FTIR spectroscopy coupled with the siMPle analytical software. This was undertaken on different water samples (sea, fresh, and wastewater) taking into consideration rinsing water, digestion protocols, collection of microplastics, and sample characteristics. Ultrapure water was the optimal rinsing water and ethanol was also proposed with a mandatory previous filtration. Although water quality could give some guidelines for the selection of digestion protocols, it is not the only decisive factor. The methodology approach by µ-FTIR spectroscopy was finally assessed to be effective and reliable. This improved quantitative and qualitative analytical methodology for microplastic detection can then be used to assess the removal efficiency of conventional and membrane treatment processes in different water treatment plants.

Large triglyceride-rich lipoproteins from fasting patients with type 2 diabetes activate platelets.

AIMS: Type 2 diabetes (T2D) patients present with risk factors for atherothrombosis such as fasting hypertriglyceridaemia and platelet hyperactivity. Our study objective was to determine the effect of large triglyceride-rich lipoproteins (TGRL) from fasting T2D patients on platelet aggregation and, if any, to identify the signaling pathway involved. METHODS: Large TGRL were isolated from the plasma of 25 T2D patients by ultracentrifugation (density < 1.000 g/mL). Platelets were isolated from healthy blood donors (HBD) and suspended in buffer, then preincubated in the presence or absence of TGRL and stimulated with either collagen or thrombin. Platelet aggregation and the arachidonic acid (AA) signaling pathway were studied. RESULTS: Fasting T2D large TGRL were mostly of hepatic origin (apoB100/apoB48 ratio: 42 ± 7) and rich in triglycerides (TG/total apoB ratio: 4.2 ± 0.5), and able to potentiate agonist-stimulated platelet aggregation (collagen: +68%, P < 0.05; thrombin: +771%, P < 0.05). It should also be mentioned that TGRL from the plasma of HBD (n = 7) had no effect on platelet aggregation. In addition, T2D large TGRL increased thromboxane B2 (TxB2) concentration in platelets stimulated with either collagen (+34%, P < 0.05) or thrombin (+37%, P < 0.05) compared with platelets stimulated with either of these agonists without TGRL. Phosphorylation of p38 MAPK and cytosolic phospholipase A2 (cPLA2) was enhanced after incubation of platelets with T2D TGRL and thrombin (+87% and +32%, respectively, P < 0.05) compared with platelets incubated with thrombin only. CONCLUSION: Large TGRL from fasting T2D patients may play a role in the development of atherothrombosis by increasing platelet aggregation and activating the platelet AA signaling pathway.

Association between difference in blood pressure reduction and risk of cardiovascular events in a type 2 diabetes population: A meta-regression analysis.

AIM: Recent US recommendations indicate a target blood pressure (BP) of 130/80mmHg for patients with type 2 diabetes (T2D). Our aim was to characterize the association between risk of cardiovascular events and differences in BP decreases in randomized trials of a T2D population. METHODS: A systematic search was made for randomized clinical trials assessing the effects of antihypertensive treatments in T2D patients on mortality, and fatal and non-fatal cardiovascular events, using a meta-regression technique to explore the influence of BP decreases on treatment effects. RESULTS: A total of 88,503 patients from 44 randomized trials were included. There was no significant association between BP decreases and risk of all-cause or cardiovascular mortality, cardiovascular events or myocardial infarction. However, stroke risk was influenced by BP decreases: compared with no reduction, a 10-mmHg reduction in systolic BP was associated with a relative odds ratio (OR) decrease of 33% (OR: 0.67, 95% CI: 0.54-0.82), and a 5-mmHg diastolic BP reduction was associated with a relative OR decrease of 38% (OR: 0.62, 95% CI: 0.50-0.76). Restricting the analysis to double-blind studies did not change the results for diastolic BP. CONCLUSION: A reduction in BP lowers the risk of stroke, but does not appear to affect the risk of other cardiovascular events in a T2D population.

Defining the Role of the Streptococcus agalactiae Sht-Family Proteins in Zinc Acquisition and Complement Evasion.

Streptococcus agalactiae is not only part of the human intestinal and urogenital microbiota but is also a leading cause of septicemia and meningitis in neonates. Its ability to cause disease depends upon the acquisition of nutrients from its environment, including the transition metal ion zinc. The primary zinc acquisition system of the pathogen is the Adc/Lmb ABC permease, which is essential for viability in zinc-restricted environments. Here, we show that in addition to the AdcCB transporter and the three zinc-binding proteins, Lmb, AdcA, and AdcAII, S. agalactiae zinc homeostasis also involves two streptococcal histidine triad (Sht) proteins. Sht and ShtII are required for zinc uptake via the Lmb and AdcAII proteins with apparent overlapping functionality and specificity. Both Sht-family proteins possess five-histidine triad motifs with similar hierarchies of importance for Zn homeostasis. Independent of its contribution to zinc homeostasis, Sht has previously been reported to bind factor H leading to predictions of a contribution to complement evasion. Here, we investigated ShtII to ascertain whether it had similar properties. Analysis of recombinant Sht and ShtII reveals that both proteins have similar affinities for factor H binding. However, neither protein aided in resistance to complement in human blood. These findings challenge prior inferences regarding the in vivo role of the Sht proteins in resisting complement-mediated clearance.IMPORTANCE This study examined the role of the two streptococcal histidine triad (Sht) proteins of Streptococcus agalactiae in zinc homeostasis and complement resistance. We showed that Sht and ShtII facilitate zinc homeostasis in conjunction with the metal-binding proteins Lmb and AdcAII. Here, we show that the Sht-family proteins are functionally redundant with overlapping roles in zinc uptake. Further, this work reveals that although the Sht-family proteins bind to factor H in vitro this did not influence survival in human blood.

Membrane filtration coupled with wet air oxidation for intensified treatment of biorefractory effluents.

This work aims to analyse the performances of a new hybrid process: membrane filtration to concentrate biorefractory wastewater before treatment by a hydrothermal process such as wet air oxidation. The aim is to obtain a complete discharge of the effluent in the environment. The three different synthetic wastewaters under study were pharmaceutical wastewater, grey wastewater and bilge wastewater. The results of the membrane filtration showed high retention rates as it could reach between 75% and 100% of total organic carbon retention, more than 99% of turbidity removal and more than 70% of hydrocarbon retention. Moreover, it was possible to achieve high concentration factors comprised between 17 and 40 times. Membrane fouling was chemically reversible regardless of the type of pollution. Then, the treatment of the membrane retentates by wet air oxidation process (300 °C, 15 MPa) could eliminate more than 83% of organic pollution for all the tested effluents. In summary, the hybrid intensified process could finally decrease the volume and the waste load of wastewater before possibly discharging it into the environment.

Single, short in-del, and copy number variations detection in monogenic dyslipidemia using a next-generation sequencing strategy.

Optimal molecular diagnosis of primary dyslipidemia is challenging to confirm the diagnosis, test and identify at risk relatives. The aim of this study was to test the application of a single targeted next-generation sequencing (NGS) panel for hypercholesterolemia, hypocholesterolemia, and hypertriglyceridemia molecular diagnosis. NGS workflow based on a custom AmpliSeq panel was designed for sequencing the most prevalent dyslipidemia-causing genes (ANGPTL3, APOA5, APOC2, APOB, GPIHBP1, LDLR, LMF1, LPL, PCSK9) on the Ion PGM Sequencer. One hundred and forty patients without molecular diagnosis were studied. In silico analyses were performed using the NextGENe software and homemade tools for detection of copy number variations (CNV). All mutations were confirmed using appropriate tools. Eighty seven variations and 4 CNV were identified, allowing a molecular diagnosis for 40/116 hypercholesterolemic patients, 5/13 hypocholesterolemic patients, and 2/11, hypertriglyceridemic patients respectively. This workflow allowed the detection of CNV contrary to our previous strategy. Some variations were found in previously unexplored regions providing an added value for genotype-phenotype correlation and familial screening. In conclusion, this new NGS process is an effective mutation detection method and allows better understanding of phenotype. Consequently this assay meets the medical need for individualized diagnosis of dyslipidemia.

Performance of a biomass adapted to oncological ward wastewater vs. biomass from municipal WWTP on the removal of pharmaceutical molecules.

The performance of a biomass adapted to Oncological Ward Wastewater (OWW) in a membrane bioreactor (MBR) was compared with that of a municipal WWTP, on the removal of pharmaceutical molecules and more specifically on their overall resistance and purifying ability in the presence of pharmaceutical cocktails. Sorption and biotransformation mechanisms on two antineoplastics, one antibiotic and a painkiller were evaluated. Sludge acclimated to OWW allowed for a 34% increase in the removal rate and in the minimum inhibition concentration. The percentage of the amounts of specific pharmaceutical compounds removed by biotransformation or by sorption were measured. These results are positive, as they show that the observed removal of pharmaceutical molecules by biomass acclimated to OWW can mostly be attributed to developed biotransformation, unlike the biomass from the municipal WWTP for which sorption is sometimes the only removal mechanism. The biotransformation kinetic and the solid-water distribution coefficients in this study show good agreement with literature data, even for much higher pharmaceutical concentrations in OWW.

Application of membrane processes in fractionation of elements in river water.

The influence of wastewater treatment plant (WWTP) effluents from one microelectronic industrial zone on element concentrations and partitioning in river water was investigated. The stepwise membrane filtration is used to distinguish different size fractions including large particulate (>18 µm), particulate (0.2-18 µm), colloidal/nanoparticle (10 kDa-0.2 µm) and truly dissolved fractions (<10 kDa) in river water samples and WWTP effluents. Results demonstrated that anthropogenic inputs (WWTP effluents and industrial area) had an important influence on concentrations and partitioning of some elements in river water. Mass balance results showed that membrane filtration processes could realize a good fractionation for many elements (good recoveries) in water samples. Flux decline during 0.2 µm and 10 kDa filtrations were analyzed, and corresponding fouling mechanisms are discussed.

Moderate oral supplementation with docosahexaenoic acid improves platelet function and oxidative stress in type 2 diabetic patients.

Platelets from patients with type 2 diabetes are characterised by hyperactivation and high level of oxidative stress. Docosahexaenoic acid (DHA) may have beneficial effects on platelet reactivity and redox status. We investigated whether moderate DHA supplementation, given as a triglyceride form, may correct platelet dysfunction and redox imbalance in patients with type 2 diabetes. We conducted a randomised, double-blind, placebo-controlled, two-period crossover trial (n=11 post-menopausal women with type 2 diabetes) to test the effects of 400 mg/day of DHA intake for two weeks on platelet aggregation, markers of arachidonic acid metabolism, lipid peroxidation status, and lipid composition. Each two week-period was separated from the other by a six-week washout. Daily moderate dose DHA supplementation resulted in reduced platelet aggregation induced by collagen (-46.5 %, p< 0.001), and decreased platelet thromboxane B2 (-35 %, p< 0.001), urinary 11-dehydro-thromboxane B2 (-13.2 %, p< 0.001) and F2-isoprostane levels (-19.6 %, p< 0.001) associated with a significant increase of plasma and platelet vitamin E concentrations (+20 % and +11.8 %, respectively, p< 0.001). The proportions of DHA increased both in plasma lipids and in platelet phospholipids. After placebo treatment, there was no effect on any parameters tested. Our findings support a significant beneficial effect of low intake of DHA on platelet function and a favourable role in reducing oxidative stress associated with diabetes.

[Spinal cord injury: still an interdisciplinary challenge [corrected]]. / Querschnittläsion : Eine bleibende interdisziplinäre Herausforderung.

INTRODUCTION: Spinal cord injuries with symptoms of paraplegia remain incurable even 5000 years after the first description. However, the treatment of the residual paralysis and sensory deficits at the level of or below the spinal injury has made great progress. METHODS: This study involved a selective literature review with an emphasis on historical development, epidemiology, classification, acute and secondary rehabilitation after spinal cord injury with specific aspects of hand surgery in tetraplegia, decubitus treatment and urological specialist care, taking the experiences in a specialized center for spinal cord injuries into account. RESULTS: Modern comprehensive management started in the 1940s led by Sir Ludwig Guttmann. Early operative decompression and stabilization of spinal injuries is safe and can reduce secondary damage to the spinal cord but definitive evidence is lacking. Operative approaches provide advantages for the patient compared to conservative therapy, e.g. being able to be immediately transferred to a specialized center. Epidemiologically, the proportion of women and the average age has increased during the past decades, as well as the percentage of patients with tetraplegia. Common sequelae of spinal cord injuries include disorders of the digestive and urogenital system, autonomic regulation, chronic pain as well as swallowing and breathing restrictions. Frequent complications, such as thrombosis and pulmonary embolism, heterotopic ossification, decubitus ulcers, contractures, neuropathic pain and spasticity can impede rehabilitation. The general objective of rehabilitation and life-long care of patients with spinal cord injuries is to achieve the greatest possible autonomy, mobility, integration, employability and quality of life. A partial recovery of arm and grip function by surgical muscle or nerve transposition, joint stabilization and tenodesis can reliably support these goals in approximately 70 % of patients with tetraplegia. CONCLUSION: Spinal cord injuries require holistic interdisciplinary therapy from the beginning and regular life-long comprehensive and specific orthopedic examinations are also required to maintain the best possible level of independence.

Chemical cleaning/disinfection and ageing of organic UF membranes: a review.

Membrane separation processes have become a basic unit operation for process design and product development. These processes are used in a variety of separation and concentration steps, but in all cases, the membranes must be cleaned regularly to remove both organic and inorganic material deposited on the surface and/or into the membrane bulk. Cleaning/disinfection is a vital step in maintaining the permeability and selectivity of the membrane in order to get the plant to its original capacity, to minimize risks of bacteriological contamination, and to make acceptable products. For this purpose, a large number of chemical cleaning/disinfection agents are commercially available. In general, these cleaning/disinfection agents have to improve the membrane flux to a certain extent. However, they can also cause irreversible damages in membrane properties and performances over the long term. Until now, there is considerably less literature dedicated to membrane ageing than to cleaning/disinfection. The knowledge in cleaning/disinfection efficiency has recently been improved. But in order to develop optimized cleaning/disinfection protocols there still remains a challenge to better understand membrane ageing. In order to compensate for the lack of correlated cleaning/disinfection and ageing data from the literature, this paper investigates cleaning/disinfection efficiencies and ageing damages of organic ultrafiltration membranes. The final aim is to provide less detrimental cleaning/disinfection procedures and to propose some guidelines which should have been taken into consideration in term of membrane ageing studies. To carry out this study, this article will detail the background of cleaning/disinfection and aging membrane topics in a first introductive part. In a second part, key factors and endpoints of cleaning/disinfection and aging membranes will be discussed deeply: the membrane role and the cleaning parameters roles, such as water quality, storing conditions, cleaning/disinfection/aging agents/conditions/protocols. The third and last part will be developed the parameters, methods and ways of characterization at our disposal and commonly used to develop and implement membrane cleaning and/or ageing studies.

Improvement in LDL-cholesterol levels of patients with familial hypercholesterolemia: can we do better? Analysis of results obtained during the past two decades in 1669 French subjects.

BACKGROUND: Heterozygous Familial Hypercholesterolemia (heFH) is an autosomal disease that affects about 1/500 people. It is characterized by markedly elevated plasma LDL-cholesterol (C) levels and an increased risk of cardiovascular disease (CVD). The aim of this study was to measure changes in LDL-C levels in heFH patients over two decades, and to evaluate if patients achieved LDL-C targets. METHODS: Data from 1669 heFH patients in five academic French centers were recorded between 1988 and 2011. RESULTS: The mean LDL-C concentrations under medical care improved between 1988 and 2011 (245 mg/dL before 1995, 164 mg/dL after 2009; p < 0.0001). However, mean LDL-C level and the number of patients treated with statins (79.3%) have not improved since 2005. In patients registered and treated after 2005 (n = 616), only 10.4% reached target LDL-C levels of <100 mg/dL. Indeed, 29.4% (n = 181) were treated with a maximal therapy (statins with a potency of >45% LDL-C reduction plus at least another lipid-lowering agent). Despite maximal treatment, only 18.8% of these heFH patients (n = 34/181) reached target LDL-C levels of <100 mg/dL. In addition, 75.3% of patients with CVD did not reach the LDL-C of <100 mg/dL. CONCLUSION: This study demonstrates that after significant improvement over the past two decades, the mean LDL-C levels in heFH French patients has remained stable since 2005. We also show that most heFH patients are not achieving their recommended LDL-C goals: this highlights the need for improved treatment and for new therapeutics in this population.

[Thiamine deficiency in infants: a case report]. / Béribéri du nourrisson : à propos d'un cas.

Thiamine deficiency is recognized in varied parts of the world. In Asia, it remains an important public health problem where highly polished rice is the major staple food and where other primary dietary sources of thiamine are in short supply. Beriberi, or clinically apparent thiamine deficiency, may present a variety of syndromes including myocardial dysfunction or wet beriberi, dry beriberi with neurological symptoms, and the more severe form Shoshin beriberi with cardiac failure and lactic acidosis. Infantile thiamine deficiency is a very rare condition in developed countries today. It occurs mainly in breastfed infants of mothers who have inadequate intake of thiamine. Clinical symptoms in such infants include gastrointestinal symptoms, cardiac failure, and lactic acidosis. We report the case of a 10-week-old girl, admitted with diarrhea, vomiting, acidosis, and cardiac failure. After excluding other etiologies of cardiomyopathy, biochemical thiamine deficiency confirmed the diagnosis of beriberi in an infant of a thiamine-deficient mother from Reunion Island, a French island where recently, with Mayotte Island, epidemic cases of beriberi have been described. This case is important to highlight the manifestations in young infants and to alert physicians to the possibility of thiamine deficiency in developed countries.

Consensus statement on the care of the hyperglycaemic/diabetic patient during and in the immediate follow-up of acute coronary syndrome.

The Diabetes and Cardiovascular Disease study group of the Société francophone du diabète (SFD, French Society of Diabetes) in collaboration with the Société française de cardiologie (SFC, French Society of Cardiology) have devised a consensus statement on the care of the hyperglycaemic/diabetic patient during and in the immediate follow-up of acute coronary syndrome (ACS); in particular, it includes the different phases of ACS [the intensive care unit (ICU) period, the post-ICU period and the short-term follow-up period after discharge, including cardiac rehabilitation] and also embraces all of the various diagnostic and therapeutic issues with a view to optimizing the collaboration between cardiologists and diabetologists. As regards diagnosis, subjects with HbA(1c) greater or equal to 6.5% on admission may be considered diabetic while, in those with no known diabetes and HbA(1c) less than 6.5%, it is recommended that an OGTT be performed 7 to 28 days after ACS. During hospitalization in the ICU, continuous insulin treatment should be initiated in all patients when admission blood glucose levels are greater or equal to 180 mg/dL (10.0 mmol/L) and, in those with previously known diabetes, when preprandial glucose levels are greater or equal to 140 mg/dL (7.77 mmol/L) during follow-up. The recommended blood glucose target is 140-180 mg/dL (7.7-10 mmol/L) for most patients. Following the ICU period, insulin treatment is not mandatory for every patient, and other antidiabetic treatments may be considered, with the choice of optimal treatment depending on the metabolic profile of the patient. Patients should be referred to a diabetologist before discharge from hospital in cases of unknown diabetes diagnosed during ACS hospitalization, of HbA(1c) greater or equal to 8% at the time of admission, or newly introduced insulin therapy or severe/repeated hypoglycaemia. Referral to a diabetologist after hospital discharge is recommended if diabetes is diagnosed by the OGTT, or during cardiac rehabilitation in cases of uncontrolled diabetes (HbA(1c) ≥ 8%) or severe/repeated hypoglycaemia.

Consensus statement on the care of the hyperglycaemic/diabetic patient during and in the immediate follow-up of acute coronary syndrome.

The Diabetes and Cardiovascular Disease study group of the Société francophone du diabète (SFD, French Society of Diabetes) in collaboration with the Société française de cardiologie (SFC, French Society of Cardiology) have devised a consensus statement on the care of the hyperglycaemic/diabetic patient during and in the immediate follow-up of acute coronary syndrome (ACS); in particular, it includes the different phases of ACS [the intensive care unit (ICU) period, the post-ICU period and the short-term follow-up period after discharge, including cardiac rehabilitation] and also embraces all of the various diagnostic and therapeutic issues with a view to optimalizing the collaboration between cardiologists and diabetologists. As regards diagnosis, subjects with HbA(1c) greater or equal to 6.5% on admission may be considered diabetic while, in those with no known diabetes and HbA(1c) less than 6.5%, it is recommended that an OGTT be performed 7 to 28days after ACS. During hospitalization in the ICU, continuous insulin treatment should be initiated in all patients when admission blood glucose levels are greater or equal to 180mg/dL (10.0mmol/L) and, in those with previously known diabetes, when preprandial glucose levels are greater or equal to 140mg/dL (7.77mmol/L) during follow-up. The recommended blood glucose target is 140-180mg/dL (7.7-10mmol/L) for most patients. Following the ICU period, insulin treatment is not mandatory for every patient, and other antidiabetic treatments may be considered, with the choice of optimal treatment depending on the metabolic profile of the patient. Patients should be referred to a diabetologist before discharge from hospital in cases of unknown diabetes diagnosed during ACS hospitalization, of HbA(1c) greater or equal to 8% at the time of admission, or newly introduced insulin therapy or severe/repeated hypoglycaemia. Referral to a diabetologist after hospital discharge is recommended if diabetes is diagnosed by the OGTT, or during cardiac rehabilitation in cases of uncontrolled diabetes (HbA(1c)≥8%) or severe/repeated hypoglycaemia.