bluuebunny/crossref_metadata_2025 huggingface dataset:
294-OR: Discovery of a Novel Secretory Protein from the Gut Microbiome That Promotes Immune Tolerance and Ameliorates Autoimmunity via Dendritic Cell Induction of IL-10
Authors: KOSTIC ALEKSANDAR
Published: June 2020

The human gut microbiota has been associated with diverse autoimmune diseases; however, the underlying mechanisms are largely unknown. To identify gut microbes and derived bioactive molecules that can promote immune tolerance, we systematically investigated the immunoregulatory potential of each member in the Altered Schaedler Flora (ASF) that has demonstrated diverse immune functions in mice. We observed that the eight ASF members presented a division of labor in promoting distinct immunophenotypes of bone marrow-derived dendritic cells, such as the production of IL-10, TNF-a, and TGF-b, and the induction of regulatory T cells. Interestingly, Parabacteroides goldsteinii ASF519 induced strong immune tolerance via novel mechanisms as evidenced by non-pan T cells-mediated promotion of Foxp3+ Treg proliferation and reduction of cytotoxic CD8 T cells, as well as TNF-a signaling-independent IL-10 production. Via bioactivity-guided fractionation, ASF519-derived molecules responsible for inducing immune tolerance were identified to be heat-labile secretory proteins with yet-uncharacterized functions. Genome-wide screening additionally identified a complex regulatory network that controls the immunoregulatory potency of ASF519. ASF519 colonization in germ-free mice significantly reduced IL-4 and IL-5 in sera and increased the transcript abundance of ll-10 and ll-17A in colon, suggesting potential roles of ASF519 in modulating both intestinal and systemic immune functions. In mouse immune disease models, oral administration of ASF519 demonstrated a protective role in the development of dextran sodium sulfate-induced colitis and collagen-induced arthritis. Relevant mechanisms are now under investigation. This study has the potential to provide novel therapeutic avenues for the prevention and treatment of autoimmune diseases.

Disclosure

A. Kostic: None.

Funding

American Diabetes Association/Pathway to Stop Diabetes (1-17-INI-13)
30-LB: Does CKD Adversely Affect the Outcome of Diabetic Patients Who Were Admitted with Diabetic Ketoacidosis? An Analysis of the Nationwide Inpatient Sample
Authors: SHAKA HAFEEZ , EDIGIN EHIZOGIE , GOMEZ TRISHA MARIE A. , XU JING , YAP SARA ELIZABETH T. , PADILLA SORTO MARIA ELENA
Published: June 2020

Background: Diabetic ketoacidosis (DKA) is managed with insulin and fluids, which can be challenging in patients with CKD. Diabetes is a common cause of CKD.

Objective: To ascertain if patients admitted with DKA with CKD had worse outcomes compared to patients without CKD.

Method: Data were extracted from the Nationwide Inpatient Sample (NIS) Database for 2016 and 2017. The numbers in the database are weighted to optimize national estimates. Hospitalizations involving adults with a principal diagnosis of DKA were included. This group was further categorized based on the presence of CKD as a secondary diagnosis. The primary outcome was inpatient mortality and secondary outcomes were Length of stay (LOS) and Total hospital Charge (THC). Multivariate regression analysis was used to adjust for possible confounders.

Results: There were 245,170 adults who had a principal discharge diagnosis of DKA, of which 22700 had a secondary diagnosis of stage 1-5 CKD or ESRD. Those with CKD were significantly older on average (45.1 vs. 34.7 years) but without sex variation, compared to those without CKD.

A total of 650 inpatient mortality (0.27%) occurred in patients with DKA, 135 occurring in patients with CKD (0.60%). After accounting for age, sex, disease severity and type of diabetes, the adjusted odds ratio (aOR) for mortality in patients with CKD compared to those without CKD was 0.89 (95% CI: 0.511 1.551, p= 0.682). CKD patients had an adjusted increase in total hospital charge of $5970 (95% CI: 2823 - 9116, p<0.001) and adjusted increase in length of hospitalization of 0.6 days ((95% CI: 0.3 - 0.8, p<0.001).

Conclusions: In patients hospitalized with a principal diagnosis of DKA, there was no significant difference in mortality among patients with co-existing CKD. A modest increase in LOS and THC was however noted in those with CKD which was statistically significant. More research needs to be done to elucidate the effect of CKD stages on these outcomes.

Disclosure

H. Shaka: None. E. Edigin: None. T.A. Gomez: None. J. Xu: None. S.T. Yap: None. M. Padilla Sorto: None.
305-OR: Glycemic Variability and Progression of CKD: PERL Substudy
Authors: MCGILL JANET B. , HIRSCH IRL B. , CALHOUN PETER , GALECKI ANDRZEJ , RUEDY KATRINA , WU CHUN-YI , DORIA ALESSANDRO
Published: June 2020

To test the hypothesis that glucose variability may impact the progression of kidney disease in type 1 diabetes (T1D), we studied a subgroup of the Preventing Early Renal Loss (PERL) study population with T1D and mild to moderate diabetic kidney disease, using blinded continuous glucose monitoring (CGM) for up to 14 days for each wear period. We studied 175 participants wearing 366 blinded FreeStyle Libre CGMs on one to five occasions between weeks 96 and 164 of the follow-up in the parent study. The mean age of the population was 52.2 ± 10.9 (mean ± SD) years, mean duration of T1D was 36.1 ± 12.2 years. Baseline BMI, A1C, and iothalamate GFR (iGFR) were 29.9 ± 6.3 kg/m2, 8.2 ± 1.2%, and 67.5 ± 17.2 ml/min/1.73m2 respectively. During the study, mean glucose (MG) and coefficient of variation glucose (CV) were 174.5 ± 41.4 mg/dL and 44.5± 8.8% respectively. Mean amplitude of glycemic excursions (MAGE) was 146.0 ± 43.9 mg/dL while time-in-range (TIR) was 50.5 ± 16.1%. A 10% increase in the mean CV was associated with a 1.4 ml/min/1.73m2 decrease in iGFR at the end of the study [95%CI (-3.33, 0.44); p=0.13] while a 10 mg/dL increase in MAGE was associated with a 0.01 ml/min/1.73m2 decrease [95%CI (-0.41, 0.38); p=0.95]. For those with CV >36, iGFR was 2.56 ml/min/1.73m2 lower compared with those with CV <36 [95%CI (-7.44, 2.31); p=0.30]. Low blood glucose index, high blood glucose index, MG, and TIR were not significantly associated with iGFR. Given the non-significant associations between CGM metrics and iGFR, we conclude in this study of a population with T1D and mild to moderate kidney disease that there is no evidence that glycemic variability or glucose control impacts the rate of loss of iGFR. Limitations of the study include the observational study design, the relatively small sample size, the variability of how frequently CGM data were collected, and the short duration of observation. A larger prospective study using real-time CGM to improve glycemic parameters and reduce glycemic variability is required to answer this question definitively.

Disclosure

J.B. McGill: Advisory Panel; Self; Aegerion Pharmaceuticals, Bayer AG, Lilly Diabetes, Novo Nordisk A/S. Consultant; Self; Boehringer Ingelheim Pharmaceuticals, Inc., Dexcom, Inc. Research Support; Self; Medtronic, Novo Nordisk Inc., Sanofi. Speaker’s Bureau; Self; Aegerion Pharmaceuticals, Dexcom, Inc., Janssen Pharmaceuticals, Inc. I.B. Hirsch: Consultant; Self; Abbott, Bigfoot Biomedical, Roche Diabetes Care. Research Support; Self; Medtronic, Omnipod. P. Calhoun: Stock/Shareholder; Self; Dexcom, Inc. A. Galecki: None. K. Ruedy: None. C. Wu: None. A. Doria: Research Support; Self; Sanofi.

Funding

The Leona M. and Harry B. Helmsley Charitable Trust (2018PG-TD1014); National Institute of Diabetes and Digestive and Kidney Diseases (R03DK094484, R34DK097808, UC4DK101108); JDRF (17-2012-377)
310-OR: Role of Glucose Flux to Elevate Hepatic Lipogenesis in Biopsy-Proven NASH
Authors: MUCINSKI JUSTINE M. , SHARMA NEAL , MOORE MARY P. , IBDAH JAMAL A. , RECTOR R. SCOTT , PARKS ELIZABETH J.
Published: June 2020

Hepatic de novo lipogenesis (DNL) contributes to the development of nonalcoholic fatty liver disease (NAFLD) and the more advanced form, nonalcoholic steatohepatitis (NASH). The purpose of the present study was to test the effects of glucose control on hepatic DNL in subjects with biopsy-proven NASH. Ten subjects [mean±SD, age 38.6±8.4y, BMI 42.2±5.9kg/m2, NAFLD activity score (NAS 1-8) of 5.7±1.3] completed metabolic studies to quantitate glucose oxidation (GluOx) measured by indirect calorimetry, liver fat by MRI/MRS, hepatic DNL using d2O administration, and VLDL-TG sources by GC/MS. Fed state GluOx was associated with NAS (Figure 1A) and fractional DNL (Figure 1B). Fasting GluOx was related to fibrosis (data not shown, r=0.690, P=0.027), ALT (r=0.631, P=0.051), AST (r=0.663, P=0.037), and absolute DNL (r=0.684, P=0.042). Subjects are participating in a 9-month diet/exercise intervention; six of whom have completed the trial increased VO2max (Figure 1C, P=0.015), reduced body mass 9.3±6.3% (P=0.008), DNL (P=0.045, n=5), liver fat (P=0.018), and ALT (P=0.001); NAS score fell from 6.3±1.0 to 3.8±2.2 (P=0.029). These data highlight how elevations in fasting and fed glycolysis can upregulate hepatic DNL to cause NASH. Lifestyle modifications that reduce DNL are likely to contribute to improvements in NAFLD/NASH.

Disclosure

J.M. Mucinski: None. N. Sharma: None. M.P. Moore: None. J.A. Ibdah: None. R. Rector: None. E.J. Parks: None.

Funding

National Institutes of Health (R01DK113701)
311-OR: Reduced Hepatic Mitochondrial Metabolism and Markers of Mitochondrial Turnover in Humans Are Linked to NAFLD Progression
Authors: MOORE MARY P. , CUNNINGHAM RORY , MEERS GRACE M. , JOHNSON SARAH A. , WHEELER ANDREW A. , GANGA RAMA RAO , PITT JAMES , SPENCER NICOLE , DIAZ-ARIAS ALBERTO A. , SWI AHMED , IBDAH JAMAL A. , PARKS ELIZABETH J. , RECTOR R S.
Published: June 2020

Considerable ambiguity exists in the literature regarding the role of hepatic mitochondrial dysfunction in the pathological progression of nonalcoholic fatty liver disease (NAFLD) to steatohepatitis (NASH) and fibrosis. To investigate this relationship, liver biopsies were obtained from patients with morbid obesity undergoing bariatric surgery [n=110, age 44.7±11.7 y, weight 136.3±25.5 kg, BMI 48.7±7.4 kg/m2, AST 35.6±32.1 U/L, ALT 41.0±35.6 U/L, NAFLD activity score 3±2 (NAS; liver injury score: steatosis, ballooning, and inflammation; range: 0-8), fibrosis score 0.5±1.0 (range: 0-4), glucose 104±33 mg/dL] and assessments of mitochondrial function and turnover performed. Data were clustered into four groups based on NAS (No Disease, NAS=0, n=13; Mild NAS=1-2, n=28; Moderate NAS=3-4, n=41; and Severe NAS≥5, n=28). Complete hepatic mitochondrial oxidation of palmitate to CO2 was reduced by ∼50% with Moderate and Severe NAS vs. no disease (p<0.05). This was accompanied by a 50% decrease in hepatic β-HAD activity in all groups with NAFLD (p<0.01), without any differences in citrate synthase activity (p>0.05). In addition to reduced hepatic mitochondrial function, elevated NAS was associated with reduced hepatic mitochondrial biogenesis (PGC1α, SIRT1, PPARα, and AMPKα1 mRNA; p<0.05) and mitochondrial turnover (BNIP3, PARKIN mRNA; p<0.05) markers. Furthermore, hepatic mitochondrial H2O2 emission was elevated in Severe NAS (p<0.01) and positively related to lobular inflammation (r=0.336, p<0.01) and hepatocellular ballooning (r=0.379, p<0.001). Here, we provide novel insight into the relationship between NAFLD severity and hepatic mitochondrial dysfunction. Our findings suggest that compromised hepatic mitochondrial fatty acid metabolism and reduced hepatic mitochondrial biogenesis/turnover may be linked to NAFLD progression in patients with morbid obesity.

Disclosure

M.P. Moore: None. R. Cunningham: None. G.M. Meers: None. S.A. Johnson: None. A.A. Wheeler: None. R. Ganga: None. J. Pitt: None. N. Spencer: None. A.A. Diaz-Arias: None. A. Swi: None. J.A. Ibdah: None. E.J. Parks: None. R.S. Rector: None.

Funding

National Institutes of Health (R01DK113701); U.S. Department of Veterans Affairs (I01BX003271)
315-OR: Hyperglycemia Increases Central Aortic Stiffness in Response to Insulin in Healthy Humans
Authors: HORTON WILLIAM B. , JAHN LINDA , HARTLINE LEE , PATRIE JAMES T. , BARRETT EUGENE
Published: June 2020

Introduction: Insulin exerts several opposing hemodynamic vascular actions, including stimulation of both nitric oxide-mediated vasodilation and endothelin-1-mediated vasoconstriction. Notably, hyperglycemia switches the vascular response to insulin from dilation to constriction in pre-clinical studies. To our knowledge, hyperglycemia’s effect on insulin’s action on vascular stiffness in humans is unknown. The American Heart Association recently recommended that vascular stiffness be determined noninvasively by carotid-femoral pulse wave velocity (cfPWV) and/or using wave separation analyses (WSA) instead of aortic augmentation index (AIx).

Methods: Thirteen lean, healthy subjects twice received a 1 mU/kg/min 2-hour insulin clamp. In one study, subjects were euglycemic and in the second, hyperglycemic (∼200 mg/dL) for 2 hours before and throughout the clamp. In each study, octreotide was infused to block endogenous insulin secretion. We assessed vascular stiffness with cfPWV, AIx, and WSA at baseline and after the 2-hour insulin clamp. Linear mixed model was used for statistical analysis, with Bonferroni correction for between-study comparisons. Spearman correlation was used to evaluate the relationship between PWV and WSA components.

Results: Compared to baseline, insulin increased cfPWV (p=0.03) during hyperglycemia without affecting AIx or components of WSA. No changes were observed during euglycemia, and insulin levels did not differ between groups. Neither AIx nor WSA components (i.e., backward and forward wave amplitude and reflection magnitude) correlated with cfPWV.

Discussion: We provide the first evidence that 4 hours of moderate hyperglycemia unmasks an action of physiologic hyperinsulinemia to increase central aortic stiffness (as measured by cfPWV) in healthy humans. Second, our results suggest that neither AIx nor WSA components correlate with cfPWV as measures of vascular stiffness.

Disclosure

W.B. Horton: None. L. Jahn: None. L. Hartline: None. J.T. Patrie: None. E. Barrett: None.
316-OR: Oral vs. Intravenous Glucose Administration Produce Opposing Microvascular Actions in Skeletal Muscle of Healthy People
Authors: ROBERTS-THOMSON KATHERINE , PARKER LEWAN , BETIK ANDREW C. , KESKE MICHELLE
Published: June 2020

Skeletal muscle microvascular blood flow (MBF) increases in response to an insulin infusion (hyperinsulinemic-euglycemic clamp) or the consumption of a mixed meal to augment glucose disposal. This microvascular action is impaired during insulin resistance. We recently demonstrated that an oral glucose challenge (50g glucose) acutely impairs skeletal muscle MBF in healthy people, compared to a mixed meal challenge, despite similar levels of hyperinsulinemia. We aimed to determine whether post-prandial hyperglycemia or gut-derived factors are the primary mediators of impaired MBF observed in response to orally ingested glucose. Seven healthy overnight-fasted subjects (sex 2M/5F, age 29±9 yrs, BMI 23.5±3.2 kg/m2, blood glucose 4.5±0.3 mM, HbA1c 5.2±0.3%, total cholesterol 3.9±1.0 mM, triglycerides 0.8±0.3 mM) underwent an oral glucose tolerance test (OGTT, 75g glucose) and an intravenous glucose tolerance test (IVGTT- bypassing the gut) matched for similar blood glucose levels, on successive visits (<4 weeks apart: cross-over design). MBF was assessed in the vastus lateralis by contrast-enhanced ultrasound at baseline, 60 and 120 minutes post-OGTT and -IVGTT. Despite similar area under the glucose time curve (OGTT: 846.8±124.8, IVGTT: 845.9±121.1 mMx2hr, P=0.98), MBF was only stimulated with the IVGTT, at 60 min (Δ MBF: OGTT -0.3± 0.5; IVGTT 0.3± 0.3 Acoustic intensity/sec, P=0.02) and 120 min post- infusion (Δ MBF: OGTT -0.4± 0.3; IVGTT 0.2± 0.3 Acoustic intensity/sec, P<0.01). Therefore, the extent of post-prandial hyperglycemia per se does not acutely impact microvascular responses in skeletal muscle in healthy humans. These data support the role of gut-derived factor(s) in the impairment of MBF following orally ingested glucose. These findings have important physiological implications for the consumption of high glycemic index meals.

Disclosure

K. Roberts-Thomson: None. L. Parker: None. A.C. Betik: None. M. Keske: None.
319-OR: First Responder Beta-Cell Subpopulation Affects Islet Response to Glucose
Authors: KRAVETS VIRA , DWULET JAEANN M. , SCHLEICHER WOLFGANG , BENNINGER RICHARD K.
Published: June 2020

Glucose-stimulated insulin secretion from the pancreatic β-cells is driven by calcium (Ca2+) uptake. In mice Ca2+ is disproportionally controlled by functional subpopulations of β-cells, identified in affecting 2nd phase oscillatory Ca2+ response. Yet, the “1st-responder” cells that lead the 1st Ca2+phase disrupted in early diabetes were overlooked. It is unknown whether 1st responders are a distinct subpopulation, and if so, which factors underlie this distinction, and what is their role. We hypothesized that 1st responder metabolic and electrical parameters are distinct from the known β-cell subpopulations, and they play an important role in the 1st Ca2+phase of the islet response. We simultaneously measured Ca2+ dynamics and electrical coupling in intact islets using β-cells specific expression of the Ca2+ sensor GCaMP6s. We performed repeated glucose and Kapt channel blocker stimulation of the islet. We used femtosecond laser ablation of specific cells. This was complimented by multicellular islet electrophysiology model where we could remove specific cells from the islet and evaluate glucokinase rate, Katp and coupling conductance of the cells. We found no overlap of 1st responder with either “wave-initiator”, leading Ca2+ wave, or highly connected “hub” cell subpopulations, based on the oscillatory 2nd phase Ca2+ wave coordination. Interestingly 1st responders were less electrically coupled (p=0.0157), supported by simulations. 1st responders were consistent under repeatable glucose stimulation and remained 1st responders under the Katp channel blocker, supported by computational results of lower than average Katp channel conductance (p<0.0001). Removing 1st responder from the islet resulted in delayed 1st phase islet response compared to the random cell removal, both in experiment and simulation (p=.0428).

In conclusion, 1st responders are distinct β-cell sub-population, which influences the islet 1st phase Ca2+response.

Disclosure

V. Kravets: None. J.M. Dwulet: None. W. Schleicher: None. R.K. Benninger: None.

Funding

JDRF (63012150); National Institutes of Health (R0163012150)
328-OR: Retinopathy Screening in Adolescents with Type 1 Diabetes
Authors: JANUSZEWSKI ANDRZEJ S. , VELAYUTHAM VALLIMAYIL , BENITEZ-AGUIRRE PAUL Z. , CRAIG MARIA E. , LIEW GERALD , CHO YOON HI , JENKINS ALICIA , DONAGHUE KIM C.
Published: June 2020

Introduction: Current ISPAD guidelines recommend biennial diabetic retinopathy (DR) screening starting at age 11 yrs with type 1 diabetes (T1D) duration 2-5 yrs. Growing evidence suggesting less frequent screening.

Methods: DR was ETDRS graded and progress assed by Markov chain model analysis. Retinal photos were from 2,169 patients (baseline (mean±SD): age 13.1±2.1 yrs, HbA1c 8.5±1.4%, 5.4±2.9 yrs T1D, follow-up 5.3±3.6 yrs) who attended the T1D clinic at least twice in 1990-2018.

Results: In 11/2,169 patients DR progressed to severe non-proliferative (SNP) DR or above. See tables 1 and 2 below for detailed results.

Conclusions: Our data support less frequent DR screening in T1D youth without any DR. Although DR progression is generally slow, poor glycaemic control greatly accelerates it.

Disclosure

A.S. Januszewski: None. V. Velayutham: None. P.Z. Benitez-Aguirre: None. M.E. Craig: None. G. Liew: None. Y. Cho: None. A. Jenkins: Advisory Panel; Self; Abbott, Medtronic. Research Support; Self; Abbott, GlySens Incorporated, Medtronic, Sanofi-Aventis. K.C. Donaghue: None.
342-OR: Optimal Ages for Screening for T1D Risk in Children
Authors: GHALWASH MOHAMED , ANAND VIBHA , HAGOPIAN WILLIAM , LUNDGREN MARKUS , REWERS MARIAN , VEIJOLA RIITTA , ZIEGLER ANETTE-GABRIELE , DUNNE JESSICA L. ,   T1DI STUDY
Published: June 2020

Screening for pre-symptomatic T1D can significantly reduce the risk of DKA at diagnosis. Screening can also identify children who may benefit from interventions to delay/prevent progression from islet autoimmunity (IA) to diabetes. To help design a rational screening schedule, we analyzed data to determine the optimal ages to screen children for IA. Longitudinal data sets from birth cohort studies (DIPP, BABYDIAB, DiPiS, and DAISY) were harmonized for analyses. We analyzed the age of screening for multiple autoantibodies to insulin, GAD and IA-2 to maximize the sensitivity and positive predictive value (PPV) to predict development of T1D by age 15. Inverse probability censoring weighting was used to account for right censored outcomes. Cumulative sensitivity, dynamic specificity, positive and negative predictive values were used to describe the models. In the combined cohorts (n=6061), a one-time screening for multiple autoantibodies achieved a maximum sensitivity of 35% and a PPV of 70-80% when applied at age 3-5 yr. To increase the sensitivity above 50% and retain PPV >70%, two screenings should occur: at 2-3 yr and at 5-6 yr (Fig). Public health screening efforts to identify children progressing to T1D must make compromises based on feasibility, cost, optimal metrics. Our data represent a starting point for these considerations that should be customized based on the population’s underlying disease characteristics and public health infrastructure.

Disclosure

M. Ghalwash: None. V. Anand: None. W. Hagopian: Consultant; Self; Novo Nordisk Inc. M. Lundgren: None. M. Rewers: None. R. Veijola: None. A. Ziegler: None. J.L. Dunne: None.
351-OR: Six-Day Subcutaneous GIP Infusion Increases Glycemic Time-in-Range in Patients with Type 1 Diabetes
Authors: NGUYEN HEIMBÜRGER SEBASTIAN M. , HOE BJØRN , NIELSEN CHRIS N. , BERGMANN NATASHA C. , HARTMANN BOLETTE , HOLST JENS J. , STØRLING JOACHIM , VILSBØLL TINA , DEJGAARD THOMAS F. , CHRISTENSEN MIKKEL B. , KNOP FILIP K.
Published: June 2020

The glucagonotropic effect of glucose-dependent insulinotropic polypeptide (GIP) during insulin-induced hypoglycemia in patients with type 1 diabetes (T1D) prompted us to investigate the effect of a 6-day subcutaneous (sc) GIP infusion on glucose variability in patients with T1D. In a randomized, placebo-controlled, double-blinded, crossover study, 20 men with T1D (age [mean± SD] 26±8 years, BMI 23.8±1.8 kg/m2, HbA1c 51±10 mmol/mol), underwent 2 × 6 days of continuous sc GIP (6 pmol/kg/min) and placebo (saline) infusion, respectively, with an interposed 7-day washout period. Participants wore a continuous glucose monitoring system. GIP significantly increased daytime time in range (3.9-7.8 mmol/L) by [mean±SEM] 104±69 min/day (P=0.035) without statistically significant effects on time below range (<3.9 mmol/L), time above range (>10.1 mmol/L), mean glucose or hypoglycemic events. Compared to placebo, GIP increased hepatic fat content by 12.6±4.2 percentage points (assessed by FibroScan®) (P=0.006), decreased 24-hour systolic and diastolic blood pressure by 4.6±2.8 (P=0.001) and 2.6±1.3 mmHg (P=0.028), respectively, and increased heart rate by 4.4±2.0 beats per minute (P=0.002) (Figure). Compared to placebo, a 6-day sc GIP infusion in patients with T1D increased glycemic time in range and hepatic fat content and reduced systolic and diastolic blood pressure while increasing heart rate.

Disclosure

S.M. Nguyen Heimbürger: None. B. Hoe: None. C.N. Nielsen: None. N.C. Bergmann: Employee; Self; Zealand Pharma A/S. B. Hartmann: None. J.J. Holst: Advisory Panel; Self; AstraZeneca, Merck Sharp & Dohme Corp., Novo Nordisk A/S, Zealand Pharma A/S. Other Relationship; Spouse/Partner; Antag Therapeutics. J. Størling: None. T. Vilsbøll: Advisory Panel; Self; AstraZeneca, Mundipharma International, Novo Nordisk A/S, Sun Pharmaceutical Industries Ltd. Consultant; Self; Boehringer Ingelheim Pharmaceuticals, Inc., Lilly Diabetes, Medscape, Merck Sharp & Dohme Corp., Sanofi. T.F. Dejgaard: Advisory Panel; Self; Novo Nordisk A/S. Consultant; Self; Boehringer Ingelheim International GmbH, Novo Nordisk A/S. Speaker’s Bureau; Self; AstraZeneca, Boehringer Ingelheim International GmbH, Novo Nordisk A/S. M.B. Christensen: None. F.K. Knop: Advisory Panel; Self; AstraZeneca, Merck Sharp & Dohme Corp., Mundipharma International, Novo Nordisk A/S, Sanofi. Consultant; Self; Carmot Therapeutics, Inc., Eli Lilly and Company, Novo Nordisk A/S. Research Support; Self; AstraZeneca, Gubra, Novo Nordisk A/S, Sanofi, Zealand Pharma A/S. Speaker’s Bureau; Self; AstraZeneca, Lupin Pharmaceuticals, Inc., Merck Sharp & Dohme Corp., Norgine B.V., Novo Nordisk A/S.

Funding

The Leona M. and Harry B. Helmsley Charitable Trust (2018PG-T1D037)
359-OR: a- or ß-Adrenergic Blockade Does Not Affect Transplanted Islet Responses to Hypoglycemia in Type 1 Diabetes (T1D)
Authors: RICKELS MICHAEL R. , BELLIN MELENA , STEFANOVSKI DARKO , PELECKIS AMY J. , DALTON-BAKES CORNELIA V. , MARKMANN EILEEN , NGUYEN HUONG-LAN T. , NAJI ALI
Published: June 2020

Recipients of intrahepatic islet transplantation for T1D exhibit appropriate suppression of endogenous insulin and activation of glucagon secretion in response to insulin-induced hypoglycemia with restored glucose counterregulation and protection against clinically significant hypoglycemia. Whether sympathetic activation of adrenergic receptors on transplanted islets is required for these responses is not known. To evaluate the adrenergic contribution to post-transplant glucose counterregulation, we performed a randomized, double-blind crossover study of responses during a hyperinsulinemic (1 mU·kg-1·min-1) euglycemic (EU, ∼90 mg/dL)-hypoglycemic (HYPO, ∼50 mg/dL) clamp conducted under phentolamine (0.95 µg·kg-1·min-1; α-adrenergic blockage), propranolol (0.48 µg·kg-1·min-1; β-adrenergic blockage), or placebo infusion. Subjects were 5F/4M with median (range) age 53 (34 - 63) years, T1D duration 29 (18 - 56) years, post-transplant 7 (2 - 8) years, HbA1c 5.8 (4.5 - 6.8) %, insulin in-/dependent 5/4, on tacrolimus-based immunosuppression, and spent 97 (76 - 99) % time in range 70 - 180 mg/dL and 1 (0 - 3) % time with hypoglycemia < 70 mg/dL by CGM. During the EU-HYPO clamp, blood pressure was lower with phentolamine and heart rate lower with propranolol vs. placebo (P < 0.05). There was no difference in suppression of C-peptide or activation of glucagon with phentolamine or propranolol vs. placebo. Pancreatic polypeptide was greater with phentolamine vs. placebo during EU (P < 0.05), and free fatty acids were lower and the glucose infusion rate higher with propranolol vs. placebo during HYPO (P < 0.05) with no differences seen for endogenous glucose production. These results indicate physiologic α- and β-adrenergic blockage had no effect on transplanted islet responses to hypoglycemia. Sympathetic re-innervation, as occurs with re-vascularization of intrahepatic islets, may not be necessary for post-transplant recovery of glucose counterregulation in T1D.

Disclosure

M.R. Rickels: Consultant; Self; Semma Therapeutics, Inc. Research Support; Self; Xeris Pharmaceuticals, Inc. M. Bellin: Research Support; Self; Dexcom, Inc., Viacyte, Inc. Other Relationship; Self; Insulet Corporation. D. Stefanovski: None. A.J. Peleckis: None. C.V. Dalton-Bakes: None. E. Markmann: None. H.T. Nguyen: None. A. Naji: None.

Funding

National Institutes of Health (R01DK091331, UL1TR001878, P30DK19525)
36-OR: Comparative Effectiveness of SGLT2 Inhibitors vs. GLP-1 Agonists
Authors: POONAWALLA INSIYA , BOWE ANDY , TINDAL MICHAEL , MEAH YUNUS A. , SCHWAB PHIL
Published: June 2020

This retrospective cohort study compared sodium-glucose co-transporter-2 (SGLT2) inhibitor and glucagon-like peptide-1 (GLP-1) agonist therapeutic drug classes on cardiovascular (CV) outcomes, treatment persistence/discontinuation, healthcare utilization and costs. Using medical and pharmacy claims data from the Humana Research Database, new users of SGLT2 inhibitors or GLP-1 agonists from January 2015 to June 2017 were identified. Eligible patients were 19-89 years, enrolled in a Medicare Advantage Prescription Drug or fully-insured commercial health plan, with at least 12 months of continuous enrollment pre- and post-index date (i.e., date of first new prescription). Propensity score matching (1:1) was used to balance baseline characteristics. Cox proportional hazards models were used to compare CV outcomes and treatment discontinuation. Healthcare resource utilization and costs were compared using Wilcoxon signed rank test. A total of 5,507 patients were included in each treatment group. Patients indexed to use GLP-1 agonists were more likely to discontinue treatment (hazard ratio 1.15, 95% confidence interval 1.10-1.21) and more likely to encounter an inpatient hospitalization (14.4% vs. 11.9%, P<0.001) or emergency department visit (27.4% vs. 23.5%, P <0.001) compared to patients indexed on SGLT2 inhibitors. The risk of primary composite CV outcome (myocardial infarction or stroke or mortality) and secondary CV outcome (heart failure or death) was similar across cohorts. The average per-person per-month total cost ($1,796 vs. $1,617, P<0.001), medical ($904 vs. $834, P<0.001) and pharmacy costs ($891 vs. $783, P<0.001) were higher for the GLP-1 agonist cohort compared to the SGLT2 inhibitor cohort. Although differences in extra-glycemic CV benefits were not established, these findings may be useful to providers and payers, as this real-world data showed SGLT2 inhibitors were associated with longer treatment persistence and reduced healthcare utilization and costs relative to GLP-1 agonists.

Disclosure

I. Poonawalla: None. A. Bowe: Employee; Self; Humana. M. Tindal: None. Y.A. Meah: None. P. Schwab: Employee; Self; Humana. Employee; Spouse/Partner; Humana.
361-OR: BETA-2 Score Is Highly Predictive of Graft Function after Islet Transplant: Analysis of Clinical Islet Transplant Consortium Trials
Authors: SENIOR PETER A. , RICKELS MICHAEL R. , EGGERMAN THOMAS , BAYMAN LEVENT , QIDWAI JULIE , ALEJANDRO RODOLFO , MARKMANN JAMES F. , HUNSICKER LAWRENCE G. ,   CLINICAL ISLET TRANSPLANT CONSORTIUM
Published: June 2020

The safety and efficacy of islet transplant for type 1 diabetes complicated by severe hypoglycemia was tested in a series of trials by the Clinical Islet Transplant (CIT) consortium. We sought to validate BETA-2 score and its utility to track change in graft function over time. 128 subjects (age 48.2 ± 10.9 years, 61.3% female) participated in 7 trials testing different approaches to immunosuppression, with 58 subjects enrolled in a follow-up observational study for up to 8 years. All subjects received 1-3 islet infusions of >4000 IE/kg at least 75 days apart. BETA-2 was calculated at 2.5, 6, 9, 12 months and then annually. Mean follow up was 45.0 months. Graft failure was defined as stimulated C-peptide < 0.3 ng/ml. The effect of time dependent BETA-2 on hazard of subsequent graft loss was estimated by joint analysis. In 120/128 subjects with graft function at day 75, CIT led to a rapid increase in BETA-2 to 24.3 ± 16.4 and remained stable for up to 8 years. 21 subjects who lost graft function after day 75 had lower BETA-2 than subjects who maintained graft function (D75: 14.5 ± 10.0 vs. 21.8 ± 11.1, p = 0.006). Joint analysis showed time dependent BETA-2 was highly predictive of graft loss (a 1 point drop in BETA-2 increased hazard of subsequent graft loss by 17% (eta = -0.19 ± 0.05, p = 0.0001). BETA-2 is a simple, yet powerful tool to describe and predict clinically important changes in graft function.

Disclosure

P.A. Senior: None. M.R. Rickels: Consultant; Self; Semma Therapeutics, Inc. Research Support; Self; Xeris Pharmaceuticals, Inc. T. Eggerman: None. L. Bayman: None. J. Qidwai: None. R. Alejandro: None. J.F. Markmann: None. L.G. Hunsicker: Advisory Panel; Self; Allergan plc., Bristol-Myers Squibb.
364-OR: Igls Classification for Islet Autotransplantation
Authors: MCEACHRON KENDALL R. , YANG YI , PRUETT TIMOTHY L. , BELLIN MELENA
Published: June 2020

Background: The Igls criteria for assessing islet function after allotransplantation cannot be directly applied to islet autotransplantation (IAT) patients due to differences in baseline characteristics of IAT patients (insulin independent and C-peptide positive).

Methods: We tested modified criteria (Auto-Igls) for assessing islet function in a large cohort of total pancreatectomy-IAT (TPIAT) patients from 2010-2018 (n=379). Metabolic outcomes post-IAT were assessed (Table 1). We assigned an Auto-Igls class to each patient as able, and evaluated the utility, validity, and perioperative predictors of Auto-Igls at 1 year post-IAT. We associated Auto-Igls with independent measures of islet graft function where available: continuous glucose monitoring (CGM) data or acute c-peptide response to glucose (ACRglu) from intravenous glucose tolerance tests.

Results: Auto-Igls class was assigned to 264 patients (69%). Of the 115 patients who could not be classified, most (74%) were missing exact insulin u/kg/day. The only significant predictor of Auto-Igls class was the islet mass transplanted (p<0.0001). Higher percent time in range (70-140 mg/dL) on CGM and higher ACRglu were associated with a better Auto-Igls class (p=0.02 and p<0.0001, respectively).

Discussion: The modified Igls criteria for IAT permit a simple, comprehensive assessment of metabolic outcomes after TPIAT, and is associated with other measures of islet function.

Disclosure

K.R. McEachron: None. Y. Yang: None. T.L. Pruett: None. M. Bellin: Research Support; Self; Dexcom, Inc., Viacyte, Inc. Other Relationship; Self; Insulet Corporation.

Funding

National Institutes of Health (T32DK108733, R01DK109124)
369-OR: [1,2-13C2]-L-Glutamine Mass Isotopomers Map Hepatic Mitochondrial Metabolism without Tracer Interference
Authors: SIEBEL STEPHAN , CARDONE REBECCA L. , ABULIZI ABUDUKADIER , RAAISA RAAISA , WILLIAMS RICHARD M. , SEHGAL RAGHAV , BUTRICO GINA MARIE , CLINE GARY , ROTHMAN DOUGLAS L. , MASON GRAEME F. , KIBBEY RICHARD
Published: June 2020

Background: Tracers should be maximally descriptive with minimal interference to the metabolic system of interest. Divergent concepts of in vivo hepatic metabolism (e.g., anaplerosis) may have emerged, in part, from invalid assumptions and/or perturbations associated with common tracers.

Aim: We evaluated three common substrate tracers for intrahepatic metabolism vis-à-vis a novel independent [1,2-13C2]-L-glutamine strategy.

Methods: Overnight fasted Sprague-Dawley rats underwent primed, continuous infusions of reported tracer rates for lactate, propionate, acetate or glutamine. Plasma/freeze-clamped livers were obtained at 0, 5, 15, 30, 60, and 120 min. Plasma/tissue isotopomers were subject to steady state and kinetic Mass Isotopomer MultiOrdinate Spectral Analysis (MIMOSA) and reported relative to citrate synthase (CS).

Results: In contrast to glutamine infusion, plasma insulin ([i]) glucose concentration ([g]), and/or plasma glucose turnover (Ra) were increased by acetate ([i] = 1.5 fold, p = 0.015; [g] = 129 mg/dl, p=0.021), lactate ([i]= 2.03 fold, p = 0.0001; [g] = 156mg/dl, p = 0.0001, Ra = 7.2 mg/kg/min, p=0.006), and propionate ([i]= 1.7 fold, p = 0.0013; [g] = 165 mg/dl, p = 0.0001, Ra = 7.8 mg/kg/min, p = 0.0017). [1,2-13C2]-L-glutamine quickly reached isotopic equilibrium without impacting mitochondrial metabolite concentration or glutamate anaplerosis. Transaminase exchange (Vx) was >>CS. PEPCK was 1.6 x CS with pyruvate only accounting for 76% of anaplerosis (remainder from propionate and glutamate anaplerosis). PK was less than CS while ATP citrate lyase (ACLy) was 18% of CS.

Conclusion: Direct in vivo measurements of pyruvate cycling rates were low relative to CS while ACLy, IDH exchange, and non-pyruvate anaplerosis contributed substantially to hepatic metabolism. [1,2-13C2]-L-glutamine MIMOSA delivered an unencumbered, direct assessment of hepatic mitochondrial metabolism.

Disclosure

S. Siebel: None. R.L. Cardone: None. A. Abulizi: None. R. Raaisa: None. R.M. Williams: None. R. Sehgal: None. G. Butrico: None. G. Cline: None. D.L. Rothman: None. G.F. Mason: None. R. Kibbey: None.

Funding

National Institutes of Health (2K12DK094714-06, R01DK108283)
371-OR: Reduced Hepatic Expression of the Mitochondrial Quality Control Factor PARKIN Hastens the Progression of NAFLD in Mice and Is Associated with NASH in Patients
Authors: UNDAMATLA RAMYA , EDMUNDS LIA R. , XIE BINGXIAN , MILLS AMANDA , SIPULA IAN J. , MONGA SATDARSHAN P. , JURCZAK MICHAEL J.
Published: June 2020

Nonalcoholic fatty liver disease (NAFLD) encompasses a spectrum of pathologies, including steatosis, steatohepatitis (NASH) and fibrosis and is strongly associated with type 2 diabetes. Changes in mitochondrial function are implicated in the pathogenesis of NAFLD. Mitophagy is a mitochondrial quality control mechanism that allows for selective removal of damaged mitochondria from the cell. Whether changes in mitophagy occur during and contribute to NAFLD is unknown. PARKIN is a ubiquitin E3 ligase that regulates mitophagy by generating a ubiquitin signaling motif on the outer membrane of damaged mitochondria, marking them for degradation. We undertook the studies described to determine effects of genetic inhibition of mitophagy via conditional deletion of PARKIN in liver on progression of NAFLD. Twelve-week old male liver-specific PARKIN knockout (LKO) and wild type (WT) mice were fed a diet previously demonstrated to induce NAFLD that consisted of high-fat (45%), cholesterol (0.15%) and high-fructose corn syrup drinking water (42g/L) for 8 weeks. There was no difference in body weight or composition between groups. Plasma ALT and AST levels were increased 2-fold (p=0.18) and 1.7-fold (p<0.05), respectively, in LKO compared with WT mice, while plasma cholesterol and insulin levels were not different and plasma fatty acid levels were reduced by 27% (p<0.05). NAFLD activity score was increased 2-fold (p<0.05) in LKO mice reflecting an increase in steatosis, ballooning and inflammation. Gene expression markers of NAFLD progression including markers of inflammation (Ccl2, Cd68, Il-1b, ll-6) and fibrosis (Col1a1, Col3a1) were significantly increased in LKO mice. Consistent with these mouse data, we found PARKIN protein expression to be reduced in liver biopsies from patients with NASH compared with healthy controls. These data suggest that loss of PARKIN-mediated mitophagy may contribute to the progression of NAFLD.

Disclosure

R. Undamatla: None. L.R. Edmunds: None. B. Xie: None. A. Mills: None. I.J. Sipula: None. S.P. Monga: None. M.J. Jurczak: None.

Funding

National Institutes of Health (DK114012)
372-OR: Ablation of the Hepatokine TSK Protects Mice against Obesity and Metabolic Disorders Caused by MC4R Deficiency
Authors: WANG QIUYU , LIN JIANDIE
Published: June 2020

Endocrine hormones released by peripheral tissues, such as adipose tissue, skeletal muscle and the liver, play an important role in metabolic crosstalk and homeostasis and contribute to disease pathogenesis. We recently identified Tsukushi (TSK) as a liver-enriched secreted factor that is highly inducible in response to increased energy expenditure. TSK null mice were resistant to diet-induced obesity, insulin resistance, and diet-induced NASH as a result of enhanced sympathetic activation and brown fat thermogenesis. However, the mechanisms underlying TSK action remain incompletely elucidated. Melanocortin 4 receptor (MC4R) is a key regulator of energy balance and its mutations represent the most common monogenic cause of obesity in human. In this study, we generated TSK/MC4R double knockout mice to explore potential crosstalk between the TSK and MC4R signaling pathways. While MC4R-null mice developed severe obesity when fed standard rodent chow, TSK inactivation nearly completely abolished the defects of energy balance caused by MC4R deficiency. Remarkably, ablation of TSK normalized food intake and corrected hepatic steatosis, adipose tissue inflammation, and insulin resistance in MC4R null mice. TSK deficiency also rescued the impairments of thermogenic gene expression caused by MC4R deficiency. Those results suggest that TSK likely acts downstream or in parallel to MC4R signaling to regulate feeding behavior and energy expenditure. Our work supports a rationale for therapeutic blockade of TSK for the treatment of obesity and metabolic disease caused by MC4R mutations.

Disclosure

Q. Wang: None. J. Lin: None.

Funding

National Institutes of Health (DK102456, AG055379, DK114220)
373-OR: Paternal SGLT2 Inhibition Upregulates Hepatic Expression of Oxidative Phosphorylation Genes in Both Fetal and Adult Offspring
Authors: SU LEI , OSATAPHAN SORAVIS , MACCHI CHIARA , CHIMENE-WEISS JEREMY I. , DREYFUSS JONATHAN , PAN HUI , PATTI MARY-ELIZABETH
Published: June 2020

Paternal obesity has a detrimental impact on metabolic health of his offspring, suggesting an opportunity for preventive strategies prior to conception. Indeed, treatment of male mice with the SGLT2 inhibitor canagliflozin (CANA, 25mg/kg/d) for 4 weeks prior to breeding reduces obesity, hepatic steatosis, and glycemia in offspring. To identify molecular mediators, we analyzed mRNA-seq in fetal and adult liver from male offspring of fathers treated with chow (pCHOW), 60% high-fat diet (pHFD), or HFD+CANA (pCANA). Differentially expressed genes were identified using Limma (R). In adult offspring, paternal SGLT2 inhibition altered the expression of 213 genes (FDR<0.05, 137 upregulated, 67 downregulated with FC ≥|1.5|, vs. paternal HFD, n=5/group). Pathway analysis revealed enrichment of oxidative phosphorylation and ribosome in upregulated genes, including 11 subunits of complex IV (Cox6b2), complex III (Uqcrq, Uqcr10), complexI(Ndufs7, Ndufa1, Ndufa2/3/7/11) and complex V(Atp5mpl, Atp5e), with similar trend for complex II Sdhb (FC=1.32, FDR=0.07). Mitochondrial DNA (quantitated by NADH dehydrogenase 1 relative to β-globin DNA) did not differ between pCANA and pHFD. To determine whether this pattern was present early in life, before emergence of offspring metabolic phenotypes, we analyzed E16.5 fetal liver. 95 genes were differentially expressed in pCANA vs. pHFD (p<0.05, 55 upregulated, 40 downregulated with FC ≥|1.5|, n=5 vs. n=3); of these, 99% were also inversely regulated by pHFD vs. pChow. 16 OXPHOS genes were downregulated by pHFD but upregulated by pCANA (FC≥|1.2|). ETFB was downregulated by pHFD (FC -1.6), but upregulated by pCANA in both fetal (FC 1.3) and adult (FC 1.5) liver.

In summary, paternal CANA modulates liver mitochondrial gene expression in his offspring during both embryonic and adult life, suggesting that improvements in oxidative capacity may mediate the protective effects of paternal SGLT2 inhibition.

Disclosure

L. Su: None. S. Osataphan: None. C. Macchi: None. J.I. Chimene-Weiss: None. J. Dreyfuss: None. H. Pan: None. M. Patti: Consultant; Self; Fractyl Laboratories, Inc. Research Support; Self; Dexcom, Inc., Xeris Pharmaceuticals, Inc. Other Relationship; Self; Academy of Nutrition and Dietetics, American Diabetes Association, American Society of Metabolic and Bariatric Surgery, Endocrine Society, Insulet Corporation, King Abdullah International Medical Research Center, SUNY Downstate.

Funding

National Institutes of Health (R01DK106193, P30DK046200)
377-P: Impact of Ramadan-Focused Education Program on Hypoglycemia Risk and Metabolic Control for Patients with Type 2 Diabetes: A Systematic Review and Meta-analysis
Authors: TOURKMANI AYLA , ALHARBI TURKI , ALRASHEEDY ALIAN , ALMADANI WIDAD , RSHEED ABDULAZIZ BIN
Published: June 2020

Ramadan fasting is regarded as a form of worship among Muslims. However, patients with a high risk of diabetic complications are advised to avoid fasting, as the practice is associated with significant impacts on several health factors for type 2 diabetic patients, including glycemic control. Thus, a lack of adequate education before Ramadan may result in negative health outcomes. To evaluate the impact of a Ramadan-focused education program on hypoglycemic risk and other clinical and metabolic parameters. A systematic literature search was performed using Scopus and PubMed to identify relevant studies meeting the inclusion criteria from inception to November 2018. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement and guidelines) were followed when performing the search and identification of appropriate studies. A total of 17 studies were included in this systemic review, with various study designs, including randomized controlled trials, quasi-experimental and non-randomized studies. Overall, the results revealed a significant reduction of hypoglycemia risk (81% reduction) for fasting patients in intervention groups who received Ramadan-focused education compared with patients receiving conventional care (OR 0.19, 95% CI: 0.08-0.46). Moreover, HbA1c was significantly improved among patients who received a Ramadan-focused education intervention, compared with those receiving conventional care. Ramadan-focused education programs had a significant impact on hypoglycemia and glycemic control, with no significant effect on body weight, blood lipids or blood pressure.

Disclosure

A. Tourkmani: None. T. Alharbi: None. A. Alrasheedy: None. W. Almadani: None. A. Bin Rsheed: None.
384-P: Impact of Concurrent Use of Oral Antidiabetes Agents with Insulin in the Real-World Hospital Setting
Authors: PATHAM BHARGAVI , CHIKERMANE SOUMYA , VADHARIYA AISHA , JOHNSON MICHAEL L. , SADHU ARCHANA R.
Published: June 2020

Guidelines recommend discontinuing oral antidiabetes drugs (OADs) on admission and initiating basal bolus insulin therapy. In the real world, concurrent OAD use with insulin is common and may affect outcomes. We conducted a large, retrospective study of 4558 patients age >18, admission >48 hours, and administered insulin >75% of days. 847 (18.58%) were administered OADs along with insulin within the first 2 days. Insulin therapy was categorized into 3 groups based on observed prescribing practices: sliding scale (SS), basal and scheduled rapid acting bolus (BB), Basal and rapid acting as needed (B+). Each group was analyzed for glucose control by days with hypoglycemia (any <70 mg/dl), hyperglycemia (mean >180 mg/dl) or euglycemia (no hypo- or hyperglycemia). Clinical outcomes included length of stay, 30/60 day readmission, and hospital mortality. Previously identified patient and provider factors that influence the choice of therapy were controlled using propensity score adjusted models. There were no statistical significant differences in hyperglycemia, euglycemia or clinical outcomes between BB or B+ compared to SS. However, hypoglycemia occurred 2 times more in BB compared to SS. B+ also had a higher trend of hypoglycemia. In our hospital system, basal insulin along with OADs resulted in more hypoglycemia. Further investigation is needed on optimizing these choices of therapy.

Disclosure

B. Patham: None. S. Chikermane: None. A. Vadhariya: None. M.L. Johnson: None. A.R. Sadhu: None.