original articleT h e ne w e ngl a nd jou r na l o f m e dic i ne n engl j med 355;13 www.nejm

SummaryBackgroundPregnant women with type 1 diabetes are a high-risk population who are recommended to strive for optimal glucose control, but neonatal outcomes attributed to maternal hyperglycaemia remain suboptimal. Our aim was to examine the effectiveness of continuous glucose monitoring (CGM) on maternal glucose control and obstetric and neonatal health outcomes.MethodsIn this multicentre, open-label, randomised controlled trial, we recruited women aged 18–40 years with type 1 diabetes for a minimum of 12 months who were receiving intensive insulin therapy. Participants were pregnant (≤13 weeks and 6 days' gestation) or planning pregnancy from 31 hospitals in Canada, England, Scotland, Spain, Italy, Ireland, and the USA. We ran two trials in parallel for pregnant participants and for participants planning pregnancy. In both trials, participants were randomly assigned to either CGM in addition to capillary glucose monitoring or capillary glucose monitoring alone. Randomisation was stratified by insulin delivery (pump or injections) and baseline glycated haemoglobin (HbA1c). The primary outcome was change in HbA1c from randomisation to 34 weeks' gestation in pregnant women and to 24 weeks or conception in women planning pregnancy, and was assessed in all randomised participants with baseline assessments. Secondary outcomes included obstetric and neonatal health outcomes, assessed with all available data without imputation. This trial is registered with ClinicalTrials.gov, number NCT01788527.FindingsBetween March 25, 2013, and March 22, 2016, we randomly assigned 325 women (215 pregnant, 110 planning pregnancy) to capillary glucose monitoring with CGM (108 pregnant and 53 planning pregnancy) or without (107 pregnant and 57 planning pregnancy). We found a small difference in HbA1c in pregnant women using CGM (mean difference −0·19%; 95% CI −0·34 to −0·03; p=0·0207). Pregnant CGM users spent more time in target (68% vs 61%; p=0·0034) and less time hyperglycaemic (27% vs 32%; p=0·0279) than did pregnant control participants, with comparable severe hypoglycaemia episodes (18 CGM and 21 control) and time spent hypoglycaemic (3% vs 4%; p=0·10). Neonatal health outcomes were significantly improved, with lower incidence of large for gestational age (odds ratio 0·51, 95% CI 0·28 to 0·90; p=0·0210), fewer neonatal intensive care admissions lasting more than 24 h (0·48; 0·26 to 0·86; p=0·0157), fewer incidences of neonatal hypoglycaemia (0·45; 0·22 to 0·89; p=0·0250), and 1-day shorter length of hospital stay (p=0·0091). We found no apparent benefit of CGM in women planning pregnancy. Adverse events occurred in 51 (48%) of CGM participants and 43 (40%) of control participants in the pregnancy trial, and in 12 (27%) of CGM participants and 21 (37%) of control participants in the planning pregnancy trial. Serious adverse events occurred in 13 (6%) participants in the pregnancy trial (eight [7%] CGM, five [5%] control) and in three (3%) participants in the planning pregnancy trial (two [4%] CGM and one [2%] control). The most...

IntroductionBone marrow (BM) is a complex tissue containing hematopoietic progenitor cells and a connective-tissue network of stromal cells. Marrow stroma includes a subpopulation of undifferentiated cells that are capable of becoming one of a number of phenotypes, including bone and cartilage, tendon, muscle, fat, and marrow stromal connective tissue that supports hematopoietic cell differentiation. 1,2 These cells are referred to as mesenchymal stem cells (MSCs), since they are known to have capacity of proliferation and differentiation into the mesenchymal lineage. Due to their potential for differentiation into different tissues, MSCs have emerged as a promising tool for clinical applications such as tissue engineering and cell and gene therapy. [3][4][5] Several reports underline the ability of MSCs to migrate. [6][7][8][9][10][11][12][13] MSCs are thought to migrate in the bloodstream to seed new sites of hematopoiesis and to various tissues during embryonic and fetal development. 14,15 MSCs are present in large numbers in human blood from at least 7 weeks' gestation and they persist until approximately 12 weeks' gestation. 14 Although circulating MSCs decrease after 12 weeks, there is evidence that a very lowfrequency population of circulating multipotent nonhematopoietic cells resembling the classical MSCs persist through to adult life. [16][17][18] MSCs migrate efficiently to hematopoietic tissues (BM and spleen) after transplantation in some experimental animal models, 19,20 whereas reports of BM homing in humans are inconsistent. [21][22][23][24][25][26] Of particular interest for tissue remodeling, intravenous delivery of MSCs results in their specific migration to a site of injury. [6][7][8]10,27 This ability of implanted MSCs to seek out the site of tissue damage has been demonstrated in bone or cartilage fracture, 28 myocardial infarction, 8,29 and ischemic cerebral injury. 6,10,11 Because MSCs have been shown to give rise to many tissues (such as bone, cartilage, fat, endothelia, muscle, brain, and pancreatic islet cells 30,31 ), migrating MSCs may represent a source of pluripotent cells that are constantly available for the repair of damaged organs. The mechanisms that guide homing of implanted cells are unclear. In this study, we examined the role of chemokines and their receptors in the migration of human MSCs. Moreover the interaction between human pancreatic islets and MSCs was investigated as a model of tissue cross talk. Material and methods Human bone marrow mesenchymal stem cell cultureHuman bone marrow mesenchymal stem cells (BM-MSCs) were obtained from Cambrex (Baltimore, MD). There were 3 different batches used for the study. Before use, the cells were analyzed for morphology, marker For personal use only. on May 11, 2018. by guest www.bloodjournal.org From expression, and osteogenic differentiation. All batches used had a fibroblastlike morphology in culture, were homogeneously CD73 ϩ , CD105 ϩ , HLA I ϩ , ␣V␤3 ϩ , ␣V␤5 ϩ , CD34 Ϫ , CD45 Ϫ , CD117 Ϫ , CD31 Ϫ , HLAII Ϫ , CD18 Ϫ , CD80...