Self-monitoring of glycaemia is a cornerstone of diabetes management, particularly for people using insulin. Traditionally, glucose monitoring involved finger-pricking and measuring capillary blood glucose concentration. Continuous glucose monitors (CGMs) have revolutionised self-monitoring of glucose levels. These devices provide continuous interstitial fluid glucose measurements, including trend arrows and alarms to alert the person if glucose levels are outside predetermined ranges. The increased reliance on CGM metrics for clinical decisions to manage diabetes necessitates the consideration and implementation of minimum standards that device manufacturers should meet to demonstrate safety, precision and accuracy. This statement provides recommendations to ensure that CGM devices that are approved for the Australian and New Zealand markets meet/exceed these minimum standards of accuracy, to provide health professionals and people living with diabetes the confidence to manage their glucose levels effectively.

Background/Objectives: Achieving a balanced wholefood diet while stabilising glycaemic management is challenging for many people with type 2 diabetes (T2D) due to barriers such as food preparation skills, time, and medication effects. Diabetes-specific nutritional formulas (DSNFs) are nutritionally complete products designed to support glycaemic management and overall nutritional adequacy and may complement wholefood dietary approaches when these are not feasible or are insufficient. Despite growing clinical evidence of efficacy, practical guidance for routine use is limited. Methods: A multidisciplinary expert working group developed a Clinical Practice Guide (CPG) for integrating DSNFs into diabetes care. Development was informed by a literature review and iterative consensus among experts, including representatives of the Australian Diabetes Society, Australian Diabetes Educators Association, and the Royal Australian College of General Practitioners. Results: The CPG outlines a three-step pathway: (1) assess suitability (clinical indications, contraindications, preferences, cultural context); (2) tailor the approach (individual goals, dose/timing relative to weight and body composition goals and observed glycaemic patterns, integration with lifestyle care); and (3) monitor progress (baseline, 2–4 weeks to assess initial response, then 3, 6, and 12 months for glycaemic indices, weight/body composition where available, and medication review). Conclusions: This CPG provides practical, multidisciplinary guidance for the person-centred use of DSNFs as an adjunct to standard care, supporting translation of current evidence into clinical practice and promoting consistent, multidisciplinary implementation.

AIMS:To assess cardiovascular risk management among Australians with diabetes. METHODS:Retrospective analysis of clinical audit data collected from diabetes centres participating in the Australian National Diabetes Audit in 2022. Adults (≥18 years) with type 1 or type 2 were included. Clinical performance was assessed by comparing modifiable cardiovascular risk factors against evidence-based clinical targets at the national and diabetes centre level for the total cohort, with sub-analyses by diabetes type, and by cardiovascular disease (CVD) status. RESULTS:There were 4341 people included; 32.4 % with type 1 and 67.6 % with type 2 diabetes. Of the total cohort, 25.9 % met the HbA1c target (≤7% or 53 mmol/mol), 45.5 % met the low-density lipoprotein cholesterol target (<2 mmol/L), 43.4 % met the systolic blood pressure target (<130 mmHg), 19.8 % met the body mass index target (<25 kg/m2), 30.2 % met the physical activity target (≥150 mins/week of moderate-to-vigorous intensity), and 85.0 % were non-smokers. Compared to patients with type 1 diabetes, patients with type 2 diabetes were less likely to meet targets. Compared to patients without existing CVD, patients with CVD were less likely to meet targets. CONCLUSIONS:Management of cardiovascular risk in adults with diabetes is sub-optimal, increasing the risk of preventable adverse health outcomes.

Aim: To investigate the association between hemoglobin (Hb) levels and incident diabetic kidney disease (DKD) in patients with type 2 diabetes. Methods: This retrospective cohort study included 1,657 patients with diabetes, without DKD at baseline, recruited from six clinics affiliated with Lee's United Clinic in Taiwan. Demographic data and laboratory results were collected and analyzed. Participants were stratified into quartiles based on their baseline Hb levels. A subgroup analysis was conducted specifically for patients with normal Hb levels (men: Hb > 120 g/l, women: Hb > 110 g/l). Cox regression analysis assessed the relation between Hb levels and incident DKD, adjusting for relevant covariates. Results: Among the initial cohort, 93 (5.6 %) had anemia at baseline. Over an average follow-up period of 5.7 f 2.6 years, 594 patients (35.8 %) developed DKD. Cox regression analysis revealed that, after adjusting for multiple variables, compared with patients in the highest quartile of baseline Hb levels (Q4: Hb > 154 g/l), the hazard of DKD was 1.6 times higher in the lowest quartile (Q1: Hb <= 130 g/l) HR [95 % CI] 1.58 [1.19;2.21] P < 0.001. In patients with normal Hb levels, Cox regression analysis also revealed that compared to the highest quartile (Q'4, Hb > 154 g/l) the hazard of developing DKD was 1.3 times higher in the lowest quartile (Q'1, Hb <= 132 g/l) HR [95 % CI ] 1.29 [1.08;1.72] P = 0.042. Conclusions: Lower Hb is associated with incident DKD, even in patients with normal Hb levels, independent of other risk factors.

Background Autonomic nerve stimulation is used as a treatment for a growing number of diseases. We have previously demonstrated that application of efferent vagus nerve stimulation (eVNS) has promising glucose lowering effects in a rat model of type 2 diabetes. This paradigm combines high frequency pulsatile stimulation to block nerve activation in the afferent direction with low frequency stimulation to activate the efferent nerve section. In this study we explored the effects of the parameters for nerve blocking on the ability to inhibit nerve activation in the afferent direction. The overarching aim is to establish a blocking stimulation strategy that could be applied using commercially available implantable pulse generators used in the clinic. Methods Male rats ( n = 20) had the anterior abdominal vagus nerve implanted with a multi-electrode cuff. Evoked compound action potentials (ECAP) were recorded at the proximal end of the electrode cuff. The efficacy of high frequency stimulation to block the afferent ECAP was assessed by changes in the threshold and saturation level of the response. Blocking frequency and duty cycle of the blocking pulses were varied while maintaining a constant 4 mA current amplitude. Results During application of blocking at lower frequencies (≤ 4 kHz), the ECAP threshold increased (ANOVA, p < 0.001) and saturation level decreased ( p < 0.001). Application of higher duty cycles (> 70%) led to an increase in evoked neural response threshold ( p < 0.001) and a decrease in saturation level ( p < 0.001). During the application of a constant pulse width and frequency (1 or 1.6 kHz, > 70% duty cycle), the charge delivered per pulse had a significant influence on the magnitude of the block (ANOVA, p = 0.003), and was focal (< 2 mm range). Conclusions This study has determined the range of frequencies, duty cycles and currents of high frequency stimulation that generate an efficacious, focal axonal block of a predominantly C-fiber tract. These findings could have potential application for the treatment of type 2 diabetes.

Tau protein is implicated in the pathogenesis of Alzheimer’s disease (AD) and other tauopathies, but its physiological function is in debate. Mostly explored in the brain, tau is also expressed in the pancreas. We further explored the mechanism of tau’s involvement in the regulation of glucose-stimulated insulin secretion (GSIS) in islet β-cells, and established a potential relationship between type 2 diabetes mellitus (T2DM) and AD. We demonstrate that pancreatic tau is crucial for insulin secretion regulation and glucose homeostasis. Tau levels were found to be elevated in β-islet cells of patients with T2DM, and loss of tau enhanced insulin secretion in cell lines, drosophila , and mice. Pharmacological or genetic suppression of tau in the db / db diabetic mouse model normalized glucose levels by promoting insulin secretion and was recapitulated by pharmacological inhibition of microtubule assembly. Clinical studies further showed that serum tau protein was positively correlated with blood glucose levels in healthy controls, which was lost in AD. These findings present tau as a common therapeutic target between AD and T2DM.

The mechanisms by which insulin activates the insulin receptor to promote metabolic processes and cellular growth are still not clear. Significant advances have been gained from recent structural studies in understanding how insulin binds to its receptor. However, the way in which specific interactions lead to either metabolic or mitogenic signalling remains unknown. Currently there are only a few examples of insulin receptor agonists that have biased signalling properties. Here we use novel insulin analogues that differ only in the chemical composition at the A6-A11 bond, as it has been changed to a rigid, non-reducible C=C linkage (dicarba bond), to reveal mechanisms underlying signaling bias. We show that introduction of an A6-A11 cis-dicarba bond into either native insulin or the basal/long acting insulin glargine results in biased signalling analogues with low mitogenic potency. This can be attributed to reduced insulin receptor activation that prevents effective receptor internalization and mitogenic signalling. Insight gained into the receptor interactions affected by insertion of an A6-A11 cis-dicarba bond will ultimately assist in the development of new insulin analogues for the treatment of diabetes that confer low mitogenic activity and therefore pose minimal risk of promoting cancer with long term use.

Background People living with diabetes must manage a range of factors for optimal control of glycaemia and to minimise the risk of diabetes-related complications. Diabetes practitioners are expected to follow guidelines for the key process of care and clinical outcomes, to help people living with diabetes achieve clinical targets. In Australia, the performance of diabetes centres against guidelines is evaluated by the Australian National Diabetes Audit, an annual clinical audit and feedback activity. Previous work has identified areas for improvement in the feedback provided to participating diabetes centres and suggested additional educational and support resources to assist in using audit feedback for the development of quality improvement activities. This cluster randomised trial will test the acceptability, utility and impact on selected clinical outcomes of the developed study intervention (audit feedback and a tailored educational and peer support cointervention). Methods Two-armed cluster randomised trial with Australian Diabetes Centres that participated in the Australian National Diabetes Audit in 2021 as the clusters, stratified by location and type of centre. We aim to recruit 35 diabetes centres in each arm. Both the intervention and control arms will receive an augmented feedback report, accompanied by a partially pre-populated slide deck. In addition, the intervention arm will receive a tailored theory-based intervention designed to address identified, modifiable barriers to utilising and implementing the recommendations from diabetes audit feedback. The co-primary outcomes are (1) HbA1c at the patient level, measured at 6 months after delivery of the intervention, and (2) the acceptability and utility of the augmented feedback and cointerventions at the practitioner level, measured at 3 months after delivery of the intervention. Discussion This trial aims to test the effects of systematic development and implementation of theory and evidence-informed changes to the audit feedback delivered to diabetes centres participating in an established national clinical diabetes audit. Potential benefits of improved audit feedback include more optimal engagement with the feedback by end clinical users which, ultimately, may lead to improvements in care for people living with diabetes. Trial registration Australian and New Zealand Clinical Trials Registry ACTRN12621000765820. Prospectively registered on June 21, 2021

Background Increasing global diabetes incidence has profound implications for health systems and for people living with diabetes. Guidelines have established clinical targets but there may be variation in clinical outcomes including HbA1c, based on location and practice size. Investigating this variation may help identify factors amenable to systemic improvement interventions. The aims of this study were to identify centre-specific and patient-specific factors associated with variation in HbA1c levels and to determine how these associations contribute to variation in performance across diabetes centres. Methods This cross-sectional study analysed data for 5,872 people with type 1 (n = 1,729) or type 2 (n = 4,143) diabetes mellitus collected through the Australian National Diabetes Audit (ANDA). A linear mixed-effects model examined centre-level and patient-level factors associated with variation in HbA1c levels. Results Mean age was: 43±17 years (type 1), 64±13 (type 2); median disease duration: 18 years (10,29) (type 1), 12 years (6,20) (type 2); female: 52% (type 1), 45% (type 2). For people with type 1 diabetes, volume of patients was associated with increases in HbA1c (p = 0.019). For people with type 2 diabetes, type of centre was associated with reduction in HbA1c (p <0.001), but location and patient volume were not. Associated patient-level factors associated with increases in HbA1c included past hyperglycaemic emergencies (type 1 and type 2, p<0.001) and Aboriginal and Torres Strait Islander status (type 2, p<0.001). Being a non-smoker was associated with reductions in HbA1c (type 1 and type 2, p<0.001). Conclusions Centre-level and patient-level factors were associated with variation in HbA1c, but patient-level factors had greater impact. Interventions targeting patient-level factors conducted at a centre level including sick-day management, smoking cessation programs and culturally appropriate diabetes education for and Aboriginal and Torres Strait Islander peoples may be more important for improving glycaemic control than targeting factors related to the Centre itself.

Obesity is a complex and multifactorial chronic disease with genetic, environmental, physiological and behavioural determinants that requires long-term care. Obesity is associated with a broad range of complications including type 2 diabetes, cardiovascular disease, dyslipidaemia, metabolic associated fatty liver disease, reproductive hormonal abnormalities, sleep apnoea, depression, osteoarthritis and certain cancers. An algorithm has been developed (with PubMed and Medline searched for all relevant articles from 1 Jan 2000-1 Oct 2021) to (i) assist primary care physicians in treatment decisions for non-pregnant adults with obesity, and (ii) provide a practical clinical tool to guide the implementation of existing guidelines (summarised in Appendix 1) for the treatment of obesity in the Australian primary care setting. MAIN RECOMMENDATIONS AND CHANGES IN MANAGEMENT: Treatment pathways should be determined by a person's anthropometry (body mass index (BMI) and waist circumference (WC)) and the presence and severity of obesity-related complications. A target of 10-15% weight loss is recommended for people with BMI 30-40 kg/m2 or abdominal obesity (WC > 88 cm in females, WC > 102 cm in males) without complications. The treatment focus should be supervised lifestyle interventions that may include a reduced or low energy diet, very low energy diet (VLED) or pharmacotherapy. For people with BMI 30-40 kg/m2 or abdominal obesity and complications, or those with BMI > 40 kg/m2 a weight loss target of 10-15% body weight is recommended, and management should include intensive interventions such as VLED, pharmacotherapy or bariatric surgery, which may be required in combination. A weight loss target of > 15% is recommended for those with BMI > 40 kg/m2 and complications and they should be referred to specialist care. Their treatment should include a VLED with or without pharmacotherapy and bariatric surgery.

Vagus nerve stimulation is emerging as a promising treatment for type 2 diabetes. Here, we evaluated the ability of stimulation of the vagus nerve to reduce glycemia in awake, freely moving metabolically compromised rats. A model of type 2 diabetes (n = 10) was induced using a high-fat diet and low doses of streptozotocin. Stimulation of the abdominal vagus nerve was achieved by pairing 15 Hz pulses on a distal pair of electrodes with high-frequency blocking stimulation (26 kHz, 4 mA) on a proximal pair of electrodes to preferentially produce efferent conducting activity (eVNS). Stimulation was well tolerated in awake, freely moving rats. During 1 h of eVNS, glycemia decreased in 90% of subjects (-1.25 +/- 1.25 mM h, p = 0.017), and 2 dB above neural threshold was established as the most effective "dose" of eVNS (p = 0.009). Following 5 weeks of implantation, eVNS was still effective, resulting in significantly decreased glycemia (-1.7 +/- 0.6 mM h, p = 0.003) during 1 h of eVNS. There were no overt changes in fascicle area or signs of histopathological damage observed in implanted vagal nerve tissue following chronic implantation and stimulation. Demonstration of the biocompatibility and safety of eVNS in awake, metabolically compromised animals is a critical first step to establishing this therapy for clinical use. With further development, eVNS could be a promising novel therapy for treating type 2 diabetes.

INTRODUCTION:Type 1 diabetes presents significant challenges for optimal management. Despite intensive glycaemic control being the standard of care for several decades, glycaemic targets are infrequently achieved and the burden of complications remains high. Therefore, the advancement of diabetes management technologies has a major role in reducing the clinical and economic impact of the disease on people living with type 1 diabetes and on health care systems. However, a national framework is needed to ensure equitable and sustainable implementation of these technologies as part of holistic care.MAIN RECOMMENDATIONS:This consensus statement considers technologies for insulin delivery, glucose sensing and insulin dose advice that are commercially available in Australia. While international position statements have provided recommendations for technology implementation, the ADS/ADEA/APEG/ADIPS Working Group believes that focus needs to shift from strict trial-based glycaemic criteria towards engagement and individualised management goals that consider the broad spectrum of benefits offered by technologies.CHANGES IN MANAGEMENT AS RESULT OF THIS STATEMENT:This Australian consensus statement from peak national bodies for the management of diabetes across the lifespan outlines a national framework for the optimal implementation of technologies for people with type 1 diabetes. The Working Group highlights issues regarding equity of access to technologies and services, scope of clinical practice, credentialling and accreditation requirements, regulatory issues with "do-it-yourself" technology, national benchmarking, safety reporting, and ongoing patient advocacy.

Medical Journal of AustraliaVolume 215, Issue 3 p. 114-115 Editorials Diabetes care for hospital patients in Australia needs repair Jeffrey D Zajac, Corresponding Author Jeffrey D Zajac j.zajac@unimelb.edu.au Austin Hospital, Melbourne, VIC The University of Melbourne, Melbourne, VIC Correspondence j.zajac@unimelb.edu.auSearch for more papers by this authorSofianos Andrikopoulos, Sofianos Andrikopoulos The University of Melbourne, Melbourne, VICSearch for more papers by this author Jeffrey D Zajac, Corresponding Author Jeffrey D Zajac j.zajac@unimelb.edu.au Austin Hospital, Melbourne, VIC The University of Melbourne, Melbourne, VIC Correspondence j.zajac@unimelb.edu.auSearch for more papers by this authorSofianos Andrikopoulos, Sofianos Andrikopoulos The University of Melbourne, Melbourne, VICSearch for more papers by this author First published: 28 June 2021 https://doi.org/10.5694/mja2.51160Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume215, Issue3August 2021Pages 114-115 RelatedInformation

Management of diabetes mellitus continues to pose challenges for primary health-care professionals, with estimates of as many as 2 million Australians requiring ongoing care. Although most cases are men, women living with diabetes have presenting concerns and self-management characteristics distinct from men. A threat to women's optimal diabetes management is being at greater risk of developing mental health conditions, especially for women with insulin-dependent type 2 diabetes. In addition, complementary medicine use is highly prevalent among women and is associated with significant direct and indirect risks, which raises clinical governance issues. To date, limited gender-specific diabetes research exists that has explored women's diabetes self-management behaviours and risk profiles. We argue that this is essential to inform the design of targeted care approaches that address clinical governance issues and help health-care professionals to better support women living with diabetes.

Abstract Background Management of glycaemia remains the mainstay of optimal diabetes care. As reported by the Australian National Diabetes Audit (ANDA) average glycaemia is suboptimal for many people living with diabetes. Whether centre-specific factors influence HbA1c variation among patients attending Australian primary, secondary or tertiary diabetes centres, is not known. Methods Data for 5,872 people with Type 1 or Type 2 diabetes (DM1/DM2) was collected for ANDA over a 4-6 week period. A linear mixed-effects model was built to examine the relative contribution of centre-specific (type of centre, location and volume of patients) and patient-specific factors in explaining variation in HbA1c, by diabetes type. Results Mean age of the cohort was 57.5±17.2 years, median disease duration 14 years (7,21) with 47% female. For people with DM1, number of patients was the only centre-specific factor that significantly contributed to HbA1c variation (p = 0.019). In contrast, for people with DM2, type of centre significantly contributed toHbA1c variation (p < 0.001). Patient-specific factors contributing to HbA1c variation included prior hyperglycaemic emergencies, being a non-smoker and Aboriginal or Torres Strait Islander status. Conclusions Unlike patient factors, centre factors such as type, location and volume of patients appear to have less actionable impact on HbA1c variation. Key messages Centre-level interventions to target patient-specific factors (such as sick day management education to prevent acute hyperglycaemia, smoking cessation programs and culturally appropriate diabetes education) rather than centre-specific factors may be more important for improving glycaemia.

Abstract Diabetic kidney disease (DKD) is a highly prevalent complication of diabetes and the leading cause of end‐stage kidney disease. Inflammation is recognized as an important driver of progression of DKD. Activation of the immune response promotes a pro‐inflammatory milieu and subsequently renal fibrosis, and a progressive loss of renal function. Although the role of the innate immune system in diabetic renal disease has been well characterized, the potential contribution of the adaptive immune system remains poorly defined. Emerging evidence in experimental models of DKD indicates an increase in the number of T cells in the circulation and in the kidney cortex, that in turn triggers secretion of inflammatory mediators such as interferon‐γ and tumor necrosis factor‐α, and activation of cells in innate immune response. In human studies, the number of T cells residing in the interstitial region of the kidney correlates with the degree of albuminuria in people with type 2 diabetes. Here, we review the role of the adaptive immune system, and associated cytokines, in the development of DKD. Furthermore, the potential therapeutic benefits of targeting the adaptive immune system as a means of preventing the progression of DKD are discussed.

The purpose of this article is to illustrate that setting standards of care is the cornerstone for excellence in diabetes management. This is underpinned by 3 activities: a standards and accreditation process, an audit and benchmarking program and a linked quality improvement plan. While there are many examples of local auditing and quality improvement programs, there are very few that are at a national level. The National Association of Diabetes Centres (NADC) was formed by the Australian Diabetes Society and the Australian Diabetes Educators Association to set standards of diabetes care in Australia. A rigorous accreditation process was put in place to recognize primary, secondary, and tertiary level diabetes centers that meet these standards. The NADC accreditation process is underpinned by a quality improvement plan, which must be submitted for accreditation to be granted and is informed by the Australian National Diabetes Audit (ANDA). ANDA is conducted annually to gather information about treatments, complications, self-care practices and quality of life outcomes and provides a national as well as an individual report to the participating center that is used to benchmark against other like centers. The ANDA reports are important to inform national policy and advocacy for diabetes care and to also provide information for quality improvement purposes for the individual participating center. We believe that the NADC Standards and Accreditation can be an exemplar for other countries to adapt and adopt to standardize diabetes care at the highest level.

The pancreatic β-cells control insulin secretion in the body to regulate glucose homeostasis, and β-cell stress and dysfunction is characteristic of Type 2 Diabetes. Pharmacological targeting of the β-cell to increase insulin secretion is typically utilised, however, extended use of common drugs such as sulfonylureas are known to result in secondary failure. Moreover, there is evidence they may induce β-cell failure in the long term. Within β-cells, insulin secretory granules (ISG) serve as compartments to store, process and traffic insulin for exocytosis. There is now growing evidence that ISG exist in multiple populations, distinct in their protein composition, motility, age, and capacity for secretion. In this review, we discuss the implications of a heterogenous ISG population in β-cells and highlight the need for more understanding into how unique ISG populations may be targeted in anti-diabetic therapies.

Medical Journal of AustraliaVolume 212, Issue 6 p. 250-251.e1 Perspective Breathing life into Australian diabetes clinical guidelines Heath White, Corresponding Author Heath White heath.white@monash.edu Monash University, Melbourne, VICheath.white@monash.eduSearch for more papers by this authorBritta Tendal, Britta Tendal Monash University, Melbourne, VICSearch for more papers by this authorJulian Elliott, Julian Elliott Monash University, Melbourne, VICSearch for more papers by this authorTari Turner, Tari Turner Monash University, Melbourne, VICSearch for more papers by this authorSofianos Andrikopoulos, Sofianos Andrikopoulos Australian Diabetes Society, Sydney, NSWSearch for more papers by this authorSophia Zoungas, Sophia Zoungas Monash University, Melbourne, VICSearch for more papers by this author Heath White, Corresponding Author Heath White heath.white@monash.edu Monash University, Melbourne, VICheath.white@monash.eduSearch for more papers by this authorBritta Tendal, Britta Tendal Monash University, Melbourne, VICSearch for more papers by this authorJulian Elliott, Julian Elliott Monash University, Melbourne, VICSearch for more papers by this authorTari Turner, Tari Turner Monash University, Melbourne, VICSearch for more papers by this authorSofianos Andrikopoulos, Sofianos Andrikopoulos Australian Diabetes Society, Sydney, NSWSearch for more papers by this authorSophia Zoungas, Sophia Zoungas Monash University, Melbourne, VICSearch for more papers by this author First published: 14 February 2020 https://doi.org/10.5694/mja2.50509Citations: 17Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article.Citing Literature Volume212, Issue6April 2020Pages 250-251.e1 RelatedInformation