Aims/hypothesisDespite improved understanding of the pathophysiology of type 2 diabetes mellitus, explanations for individual variability in disease progression and response to treatment are incomplete. The gut microbiota has been linked to the pathophysiology of type 2 diabetes mellitus and may account for this variability. We conducted a systematic review to assess the effectiveness of dietary and physical activity/exercise interventions in modulating the gut microbiota and improving glucose control in adults with type 2 diabetes mellitus.MethodsA systematic search was conducted to identify studies reporting on the effect of dietary and physical activity/exercise interventions on the gut microbiota and glucose control in individuals with a confirmed diagnosis of type 2 diabetes mellitus. Study characteristics, methodological quality and details relating to interventions were captured using a data-extraction form. Meta-analyses were conducted where sufficient data were available, and other results were reported narratively.ResultsEight studies met the eligibility criteria of the systematic review. No studies were found that reported on the effects of physical activity/exercise on the gut microbiota and glucose control. However, studies reporting on dietary interventions showed that such interventions were associated with modifications to the composition and diversity of the gut microbiota. There was a statistically significant improvement in HbA1c (standardised mean difference [SMD] −2.31 mmol/mol [95% CI −2.76, −1.85] [0.21%; 95% CI −0.26, −0.16]; I2 = 0%, p < 0.01), but not in fasting blood glucose (SMD −0.25 mmol/l [95% CI −0.85, 0.35], I2 = 87%, p > 0.05), fasting insulin (SMD −1.82 pmol/l [95% CI −7.23, 3.60], I2 = 54%, p > 0.05) or HOMA-IR (SMD −0.15 [95% CI −0.63, 0.32], I2 = 69%, p > 0.05) when comparing dietary interventions with comparator groups. There were no significant changes in the relative abundance of bacteria in the genera Bifidobacterium (SMD 1.29% [95% CI −4.45, 7.03], I2 = 33%, p > 0.05), Roseburia (SMD −0.85% [95% CI −2.91, 1.21], I2 = 79%, p > 0.05) or Lactobacillus (SMD 0.04% [95% CI −0.01, 0.09], I2 = 0%, p > 0.05) when comparing dietary interventions with comparator groups. There were, however, other significant changes in the gut microbiota, including changes at various taxonomic levels, including phylum, family, genus and species, Firmicutes:Bacteroidetes ratios and changes in diversity matrices (α and β). Dietary intervention had minimal or no effect on inflammation, short-chain fatty acids or anthropometrics.Conclusions/interpretationDietary intervention was found to modulate the gut microbiota and improve glucose control in individuals with type 2 diabetes. Although the results of the included studies are encouraging, this review highlights the need for further well-conducted interventional studies to inform the clinical use of dietary interventions targeting the gut microbiota.Electronic supplementary materialThe online version of this article (10.1007/s00125-018-4632-0) contains...

BackgroundNon-alcoholic fatty liver disease (NAFLD) is common and is associated with liver-related and cardiovascular-related morbidity. Our aims were: (1) to review the current management of patients with NAFLD attending hospital clinics in North East England (NEE) and assess the variability in care; (2) develop a NAFLD ‘care bundle’ to standardise care; (3) to assess the impact of implementation of the NAFLD care bundle.MethodsA retrospective review was conducted to determine baseline management of patients with NAFLD attending seven hospitals in NEE. A care bundle for the management of NAFLD was developed including important recommendations from international guidelines. Impact of implementation of the bundle was evaluated prospectively in a single centre.ResultsBaseline management was assessed in 147 patients attending gastroenterology, hepatology and a specialist NAFLD clinic. Overall, there was significant variability in the lifestyle advice given and management of metabolic risk factors, with patients attending an NAFLD clinic significantly more likely to achieve >10% body weight loss and have metabolic risk factors addressed. Following introduction of the NAFLD bundle 50 patients were evaluated. Use of the bundle was associated with significantly better documentation and implementation of most aspects of patient management including management of metabolic risk factors, documented lifestyle advice and provision of NAFLD-specific patient advice booklets.ConclusionThe introduction of an outpatient ‘care bundle’ led to significant improvements in the assessment and management of patients with NAFLD in the NEE and could help improve and standardise care if used more widely.

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Purpose of Review Non-alcoholic fatty liver disease (NAFLD) is the most common liver disease in the Western world. Invasive liver biopsy remains the gold standard method for the diagnosis and staging of NAFLD. The aim of this review is to summarize recent research regarding imagingbased assessment of NAFLD. Recent Findings Novel methods such as controlled attenuation parameter (CAP) and magnetic resonance imaging proton-derived fat fraction (MRI-PDFF) appear promising for steatosis assessment and are currently undergoing validation in NAFLD. Fibrosis can be non-invasively assessed by transient elastography (TE), which is currently the best validated test in NAFLD. MR elastography (MRE) appears very sensitive for fibrosis detection. No imaging technique can accurately detect NASH. Summary TE is inexpensive and relatively widely available and can reliably exclude advanced fibrosis in NAFLD. MRI offers the most promise for steatosis and fibrosis quantification, but further validation of these techniques is needed.

[ MEDICALJ concerning it. A number of patients who are going to make uninterrupted recoveries have very slow pulse rates indeed, it is quite impossible to tell from the initial pulse rate alone what the prognosis of the case is going to be.It is true that a very slow pulse rate is a danger signal, but it can very well be a false alarm.A.-Pulse rate on admission of a series of fatal cases: 64, 88, 96, 80, 60, 56, 140, 54, 88, 50. B.-Pulse rate oIn admission of a series of recoveries: 88, 72, 76, 58, 140, 80, 72, 64, 68, 50, 76. An interesting point is the fact that a very slow pulse rate may develop after the first few days and remain during the period of recovery. In children, in particular, the initial rate is fast, whilst in adults primary shock, a condition seen in purity only in uncomplicated head injuries, will equally cause a rapid pulse. On the whole, slow pulse rates are seen during the first few hours more commonly in the fatal cases than in others. There is, however, a very interesting phenomenon to which I wish to call attention, and that is secondary bradycardia setting in towards the end of the first week and continuing during the second. This has been a not uncommon findino in the present series, and is due to reactionary oedema. Often enough the patients during this phase have been entirely conscious, and apart from the bradycardia their condition has given rise to no alarm. Sometimes they.have had very severe headache, but not necessarily so; sometimes no more than a feeling of fullness or oppression in the head has been experienced. We have often kept a patient back in hospital on account of his slow pulse when he has felt well and pressed for his release, and then, no untoward signs having developed, he has finally been allowed to go. It might be assumed that in all such cases with secondary bradycardia the cerebro-spinal fluid pressures would be elevated, but in three separate cases with pulse rates of 56, 48, 54, the cerebro-spinal fluid pressure registered 1 1, 10, 11 cm. respectively-that is, entirely normal readings. The accompanying chart (Fig. 2) 60 -illustrates secondary bradycardia continuing over several davs in a patient making a perfect clinical recovery, and this chart could be duplicated many times from our material.In conclusion, I believe that the classification of head injuries on a basis of stupor is a more correct method than that which categorizes the cases according to evidences of fracture. This alteration I have made tentatively to-day.Signs of local contusion must be -carefully looked for and recorded, whilst every effort is made to distinguish the epiphenomena, the alterations in behaviour and clinical state induced by the laying down of another conditionlocal compression by subdural or epidural haematoma on the " basic state "of general contusion.

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