Individual categorisation of glucose profiles using compositional data analysis

The aim of this study was to apply a methodology based on compositional data analysis (CoDA) to categorise glucose profiles obtained from continuous glucose monitoring systems. The methodology proposed considers complete daily glucose profiles obtained from six patients with type 1 diabetes (T1D) who had their glucose monitored for eight weeks. The glucose profiles were distributed into the time spent in six different ranges. The time in one day is finite and limited to 24 h, and the times spent in each of these different ranges are co-dependent and carry only relative information; therefore, CoDA is applied to these profiles. A K-means algorithm was applied to the coordinates obtained from the CoDA to obtain different patterns of days for each patient. Groups of days with relatively high time in the hypo and/or hyperglycaemic ranges and with different glucose variability were observed. Using CoDA of time in different ranges, individual glucose profiles were categorised into groups of days, which can be used by physicians to detect the different conditions of patients and personalise patient's insulin therapy according to each group. This approach can be useful to assist physicians and patients in managing the day-to-day variability that hinders glycaemic control.

A national survey on the efficacy and safety of continuous subcutaneous insulin infusion in patients with type 1 diabetes in Spain

AIMS

To assess safety and benefits of continuous subcutaneous insulin infusion (CSII) therapy in a cohort of type 1 diabetes patients in Spain.

METHODS

A web-based national registry was created by the Working Group of the Spanish Diabetes Association. All patients on CSII being followed at selected referral centers were included. A cross-sectional analysis was performed.

RESULTS

A total of 1275 patients were included. Data completion for patients on CSII was 67 ± 32%. Indications for treatment were suboptimal glycemic control (32%), high glucose variability (24%), preconception care (14%) and hypoglycemia (11%). In the patients on CSII for ≥1 year (n = 843, mean CSII duration of 5 years), HbA_1c decreased by 5 mmol/mol (0.5%) in the whole population and by 8 mmol/mol (0.7%) in subjects with suboptimal glycemic control as CSII indication. Percentage of patients achieving HbA_1c ≤ 53 mmol/mol (7%) increased from 20% before CSII to 34% at the end of follow-up. Severe hypoglycemia decreased from 29% to 5%. The rate of discontinuation was 9.5%. HbA_1c was lower in patients using bolus advisor and temporary basal rates.

CONCLUSIONS

CSII was associated with a sustained improvement in glycemic control and a reduction in severe hypoglycemia. The use of advanced CSII settings was related to better glycemic control.

Automatic Adaptation of Basal Insulin Using Sensor-Augmented Pump Therapy

BACKGROUND

People with insulin-dependent diabetes rely on an intensified insulin regimen. Despite several guidelines, they are usually impractical and fall short in achieving optimal glycemic outcomes. In this work, a novel technique for automatic adaptation of the basal insulin profile of people with diabetes on sensor-augmented pump therapy is presented.

METHODS

The presented technique is based on a run-to-run control law that overcomes some of the limitations of previously proposed methods. To prove its validity, an in silico validation was performed. Finally, the artificial intelligence technique of case-based reasoning is proposed as a potential solution to deal with variability in basal insulin requirements.

RESULTS

Over a period of 4 months, the proposed run-to-run control law successfully adapts the basal insulin profile of a virtual population (10 adults, 10 adolescents, and 10 children). In particular, average percentage time in target [70, 180] mg/dl was significantly improved over the evaluated period (first week versus last week): 70.9 ± 11.8 versus 91.1 ± 4.4 (adults), 46.5 ± 11.9 versus 80.1 ± 10.9 (adolescents), 49.4 ± 12.9 versus 73.7 ± 4.1 (children). Average percentage time in hypoglycemia (<70 mg/dl) was also significantly reduced: 9.7 ± 6.6 versus 0.9 ± 1.2 (adults), 10.5 ± 8.3 versus 0.83 ± 1.0 (adolescents), 10.9 ± 6.1 versus 3.2 ± 3.5 (children). When compared against an existing technique over the whole evaluated period, the presented approach achieved superior results on percentage of time in hypoglycemia: 3.9 ± 2.6 versus 2.6 ± 2.2 (adults), 2.9 ± 1.9 versus 2.0 ± 1.5 (adolescents), 4.6 ± 2.8 versus 3.5 ± 2.0 (children), without increasing the percentage time in hyperglycemia.

CONCLUSION

The present study shows the potential of a novel technique to effectively adjust the basal insulin profile of a type 1 diabetes population on sensor-augmented insulin pump therapy.

Blood glucose monitoring during aerobic and anaerobic physical exercise using a new artificial pancreas system

AIM

To assess an artificial pancreas system during aerobic (AeE) and anaerobic exercise (AnE).

METHODS

A pilot clinical trial on five subjects with type 1 diabetes (4 males) aged 37±10.9 years, diabetes diagnosed 21.2±12.2 years before, insulin pump users, and with a mean HbA_1c level of 7.8±0.5%. Every subject did three AeE and three AnE sessions. Blood glucose levels were monitored by the artificial pancreas system during exercise and up to four hours later. Before the start of exercise, 23g of carbohydrates were administered orally.

RESULTS

The mean glucose level was 124.0±25.1mg/dL in the AeE studies and 152.1±34.1mg/dL in the AnE studies. Percent times in the different glucose ranges of 70-180, >180 and <70mg/dL were 89.8±18.6% and 75.9±27.6%; 7.7±18.4% and 23.2±28.0%; and 2.5±6.3% and 1.0±3.6% during the AeE and AnE sessions, respectively. Only six rescues with carbohydrates (15g) were required during the studies (4 in AeE and 2 in AnE). Total insulin dose during the five hours of the study was 3.1±1.0IU in the AeE studies and 3.5±1.3IU in the AnE studies.

CONCLUSIONS

Blood glucose response to AeE and AnE exercise is different. The evaluated artificial pancreas system appeared to achieve effective and safe blood glucose control during exercise and up to four hours later. However, new control strategies that minimize patient intervention should be designed.

Extensive Assessment of Blood Glucose Monitoring During Postprandial Period and Its Impact on Closed-Loop Performance

BACKGROUND

Closed-loop (CL) systems aims to outperform usual treatments in blood glucose control and continuous glucose monitors (CGM) are a key component in such systems. Meals represents one of the main disturbances in blood glucose control, and postprandial period (PP) is a challenging situation for both CL system and CGM accuracy.

METHODS

We performed an extensive analysis of sensor's performance by numerical accuracy and precision during PP, as well as its influence in blood glucose control under CL therapy.

RESULTS

During PP the mean absolute relative difference (MARD) for both sensors presented lower accuracy in the hypoglycemic range (19.4 ± 12.8%) than in other ranges (12.2 ± 8.6% in euglycemic range and 9.3 ± 9.3% in hyperglycemic range). The overall MARD was 12.1 ± 8.2%. We have also observed lower MARD for rates of change between 0 and 2 mg/dl. In CL therapy, the 10 trials with the best sensor spent less time in hypoglycemia (PG < 70 mg/dl) than the 10 trials with the worst sensors (2 ± 7 minutes vs 32 ± 38 minutes, respectively).

CONCLUSIONS

In terms of accuracy, our results resemble to previously reported. Furthermore, our results showed that sensors with the lowest MARD spent less time in hypoglycemic range, indicating that the performance of CL algorithm to control PP was related to sensor accuracy.

Closed-Loop Control of Postprandial Glycemia Using an Insulin-on-Board Limitation Through Continuous Action on Glucose Target

BACKGROUND

Postprandial (PP) control remains a challenge for closed-loop (CL) systems. Few studies with inconsistent results have systematically investigated the PP period.

OBJECTIVE

To compare a new CL algorithm with current pump therapy (open loop [OL]) in the PP glucose control in type 1 diabetes (T1D) subjects.

METHODS

A crossover randomized study was performed in two centers. Twenty T1D subjects (F/M 13/7, age 40.7 ± 10.4 years, disease duration 22.6 ± 9.9 years, and A1c 7.8% ± 0.7%) underwent an 8-h mixed meal test on four occasions. In two (CL1/CL2), after meal announcement, a bolus was given followed by an algorithm-driven basal infusion based on continuous glucose monitoring (CGM). Alternatively, in OL1/OL2 conventional pump therapy was used. Main outcome measures were as follows: glucose variability, estimated with the coefficient of variation (CV) of the area under the curve (AUC) of plasma glucose (PG) and CGM values, and from the analysis of the glucose time series; mean, maximum (C_max), and time to C_max glucose concentrations and time in range (<70, 70-180, >180 mg/dL).

RESULTS

CVs of the glucose AUCs were low and similar in all studies (around 10%). However, CL achieved greater reproducibility and better PG control in the PP period: CL1 = CL2<OL1<OL2 (PG_mean 123 ± 47 and 125 ± 44 vs. 152 ± 53 and 159 ± 54 mg/dL) and C_max OL 217.1 ± 67.0 mg/dL versus CL 183.3 ± 63.9 mg/dL, P < 0.0001. Time-in-range was higher with CL versus OL (80% vs. 64%; P < 0.001). Neither the time below 70 mg/dL (CL 6.1% vs. OL 3.2%; P > 0.05) nor the need for oral glucose was significantly different (CL 40.0% vs. OL 22.5% of meals; P = 0.054).

CONCLUSIONS

This novel CL algorithm effectively and consistently controls PP glucose excursions without increasing hypoglycemia. Study registered at ClinicalTrials.gov : study number NCT02100488.

Profiling intra-patient type I diabetes behaviors

BACKGROUND

The large intra-patient variability in type 1 diabetic patients dramatically reduces the ability to achieve adequate blood glucose control. A novel methodology to identify different blood glucose dynamics profiles will allow therapies to be more accurate and tailored according to patient's conditions and to the situations faced by patients (exercise, week-ends, holidays, menstruation, etc).

MATERIALS AND METHODS

A clustering methodology based on the normalized compression distance is applied to identify different profiles for diabetic patients. First, the methodology is validated using "in silico" data from 10 patients in 3 different scenarios: days without exercise, poor controlled exercise days and days with well-controlled exercise. Second, we perform a series of in vivo experiments using data from 10 patients assessing the ability of the proposed methodology in real scenarios.

RESULTS

In silico experiments show that the methodology is able to identify poor and well-controlled days in theoretical scenarios. In vivo experiments present meaningful profiles for working days, bank days and other situations, where different insulin requirements were detected.

CONCLUSIONS

A tool for profiling blood glucose dynamics of patients can be implemented in a short term to enhance existing analysis platforms using combined CGM-CSII systems. Besides coping with the information overload, the tool will assist physicians to adjust and improve insulin therapy and patients in the self-management of the disease.

Long-term outcome of insulin pump therapy: reduction of hypoglycaemia and impact on glycaemic control

AIMS

To determine the long-term outcome of continuous subcutaneous insulin infusion (CSII) in Type 1 diabetes according to Catalan National Health Service indications.

METHODS

Retrospective observational study including 178 patients with Type 1 diabetes who started CSII treatment in our centre (2003-2008). All patients were followed in our CSII programme for outpatients for at least 5 years. Data on annual HbA1c levels were collected, and the main indication for starting CSII was analysed.

RESULTS

Twenty-seven of 178 patients were excluded because of loss to follow-up or withdrawal from CSII, thus 151 patients (aged 37.4 ± 10.5 years, 64% women) were analysed. The main indications for starting CSII were suboptimal metabolic control (60.9%), severe hypoglycaemia/hypoglycaemia unawareness (25.5%) and others (13.6%). HbA1c was 64 ± 13 mmol/mol (8.0 ± 1.2%) at the start of CSII and 62 ± 13 mmol/mol (7.8 ± 1.2%) after 5 years in the total cohort (P = 0.1). The severe hypoglycaemia rates were 0.66 ± 1.61 and 0.17 ± 0.42 episodes/patient/year (P < 0.001). In patients with suboptimal metabolic control, HbA1c decreased from 68 ± 12 mmol/mol (8.4 ± 1.1%) to 64 ± 14 mmol/mol (8.0 ± 1.3%) (P = 0.016), with 37.4% of those in this group having an HbA1c ≤ 58 mmol/mol (7.5%) after 5 years. In patients starting CSII due to severe hypoglycaemia the problem was considered resolved in 93%, and in 64% of those starting CSII because of suboptimal glycaemic control, HbA1c improved significantly.

CONCLUSIONS

CSII therapy achieves and maintains its efficacy mainly in terms of reducing severe hypoglycaemia. In the whole group of patients, the reduction in HbA1c is transient and disappears after 5 years.

Metabolic control after years of completing a clinical trial on sensor-augmented pump therapy

BACKGROUND

Sensor-augmented pump (SAP) therapy has been shown to be effective and safe for improving metabolic control in patients with type 1 diabetes mellitus (T1DM) in a number of trials. Our objective was to assess glycemic control in a group of T1DM patients on insulin pump or SAP therapy after years of participating in the SWITCH (Sensing With Insulin pump Therapy To Control HbA1c) trial and their return to routine medical monitoring.

METHODS

A retrospective, observational study of 20 patients who participated in the SWITCH trial at our hospital from 2008 to 2010. HbA1c values were compared at the start, during (at the end of the periods with/without SAP use - Sensor On/Sensor Off period respectively - of the cross-over design), and 3 years after study completion. HbA1c values of patients who continued SAP therapy (n=6) or only used insulin pump (n=14) were also compared.

RESULTS

Twenty patients with T1DM (44.4±9.3 years, 60% women, baseline HbA1c level 8.43±0.55%) were enrolled into the SWITCH study). Three years after study completion, HbA1c level was 7.79±0.77 in patients on pump alone, with no significant change from the value at the end of the Off period of the study (7.85±0.57%; p=0.961). As compared to the end of the On period, HbA1c worsened less in patients who remained on SAP than in those on pump alone (0.18±0.42 vs. 0.55±0.71%; p=0.171), despite the fact that levels were similar at study start (8.41±0.60 vs. 8.47±0.45; p=0.831) and at the end of the On period (7.24±0.48 vs. 7.38±0.61; p=0.566). Frequency of CGM use in patients who continued SAP therapy was high (61.2% of the time in the last 3 months).

CONCLUSIONS

Our study suggests that the additional benefit of SAP therapy achieved in a clinical trial may persist in the long term in routine clinical care of patients with T1DM.

[Cardiovascular disease in patients with type 1 and type 2 diabetes in Spain]

BACKGROUND AND OBJECTIVE

To describe the prevalence of cardiovascular disease (CVD) in type 1 diabetes (T1DM) and to compare it with that observed in type 2 diabetes (T2DM) and normal population in Spain.

PATIENTS AND METHODS

Cross-sectional study (18-70 years-old). Information on CVD was available from a nurse-administered questionnaire (Di@bet.es Study, NORMAL=3,430, T2DM=312) and from a physician reporting form (T1DM=1,382). Differences in the crude and adjusted prevalence of coronary heart (CHD), cerebrovascular (CNSD), peripheral vascular (PVD) and overall CV (CVD) disease were investigated between T1DM vs. NORMAL, and T1DM vs. T2DM groups.

RESULTS

We found differences in age, body mass index, proportion of women, dyslipemia and antihypertensive medication between T1DM vs. NORMAL and T1DM vs. T2DM (all P<.001). Smoking prevalence was not different between T1DM vs. T2DM and it was lower in T1DM compared to NORMAL (P<.0001). The percentage of CHD, CNSD, PVD, and overall CVD in T1DM vs. NORMAL was 3.0 vs. 2.5 (P=.31), 0.70 vs. 1.10 (P=.22), 2.61 vs. 0.20 (P<.0001), and 5.1 vs. 3.44 (P<.01), respectively. The prevalence in T2DM (vs. T1DM) was 11.3 (P<.0001), 3.5 (P<.0001), 4.2 (P=.13), and 17% (P<.0001), respectively. Multiple logistic regression adjusted models showed a higher prevalence of CHD (odds ratio [OR] 2.27, 95% confidence interval [95% CI] 1.41-3.67), PVD (OR 15.35, 95% CI 5.61-42.04), and overall CVD (OR 2.32, 95% CI 1.55-3.46), but not for CNSD (OR 0.49, 95% CI 0.19-1.27) in T1DM compared to NORMAL. No differences were found between T1DM and T2DM.

CONCLUSIONS

We found a higher prevalence of CVD in a Mediterranean population of T1DM individuals compared with non-diabetic subjects. This prevalence was similar to that observed in T2DM.

Transitory beneficial effects of professional continuous glucose monitoring on the metabolic control of patients with type 1 diabetes

BACKGROUND

The benefit of professional continuous glucose monitoring (PCGM) in the metabolic control of patients with type 1 diabetes mellitus (T1DM) is uncertain.

SUBJECTS AND METHODS

This was a retrospective study of all consecutive T1DM patients who underwent a 6-day PCGM in our Diabetes Unit over the course of 17 months. According to the indication, two groups were arbitrarily defined: "hyperglycemic" and "hypoglycemic." Data from medical files and sensor reports were reviewed. Glycated hemoglobin (HbA1c) was evaluated 2-4 weeks prior to PCGM, as well as 3-5 and 12 months after PCGM. In the hypoglycemic group, the number of self-reported mild hypoglycemic episodes (as defined by the American Diabetes Association) was collected.

RESULTS

Of the 67 patients reviewed, 43 were in the hyperglycemic group, and 24 were in the hypoglycemic group. In the hyperglycemic group, the HbA1c level dropped at 3-5 months post-intervention from 8.45 ± 0.72% to 8.04 ± 0.9%, with the decline being statistically significant (-0.4%; P = 0.001) and positively correlated with the initial HbA1c value (0.366; P=0.016). One year after the PCGM study, the HbA1c level tended to return to the initial values: 8.20 ± 1.05% (-0.24%; P = 0.081). In the hypoglycemic group, HbA1c did not change either 3-5 or 12 months after PCGM, although the percentage of patients in whom the number of mild hypoglycemic episodes was significantly reduced was 86% (P=0.001).

CONCLUSIONS

Although a transient phenomenon, PCGM can be useful in the short term in improving metabolic and clinical profile of suboptimally controlled T1DM subjects, including those with repeated hypoglycemia.

Neural response to the observable self in social anxiety disorder

BACKGROUND

Distorted images of the observable self are considered crucial in the development and maintenance of social anxiety. We generated an experimental situation in which participants viewed themselves from an observer's perspective when exposed to scrutiny and evaluation by others. Method Twenty patients with social anxiety disorder (SAD) and 20 control subjects were assessed using functional magnetic resonance imaging (fMRI) during the public exposure of pre-recorded videos in which they were each shown performing a verbal task. The examiners acted as the audience in the experiment and rated performance. Whole-brain functional maps were computed using Statistical Parametric Mapping.

RESULTS

Robust activation was observed in regions related to self-face recognition, emotional response and general arousal in both study groups. Patients showed significantly greater activation only in the primary visual cortex. By contrast, they showed significant deactivation or smaller activation in dorsal frontoparietal and anterior cingulate cortices relevant to the cognitive control of negative emotion. Task-related anxiety ratings revealed a pattern of negative correlation with activation in this frontoparietal/cingulate network. Importantly, the relationship between social anxiety scores and neural response showed an inverted-U function with positive correlations in the lower score range and negative correlations in the higher range.

CONCLUSIONS

Our findings suggest that exposure to scrutiny and evaluation in SAD may be associated with changes in cortical systems mediating the cognitive components of anxiety. Disorder severity seems to be relevant in shaping the neural response pattern, which is distinctively characterized by a reduced cortical response in the most severe cases.

Psychometric analysis of the Spanish and Catalan versions of the Diabetes Self-Care inventory-revised version questionnaire

BACKGROUND

The purpose of this study was to validate the Spanish and Catalan versions of the Diabetes Self-Care Inventory-Revised Version (SCI-R) questionnaire to assess the degree of adherence to self-care among adults with diabetes.

METHODS

We validated the Spanish and Catalan translation from, and back translation to, English and cultural adaptation of the SCI-R in type 1 diabetes patients on multiple insulin doses or continuous subcutaneous insulin infusion and in type 2 diabetes patients on oral agents and/or insulin. Internal reliability, structural validity, and external validity (correlation with glycated hemoglobin) were evaluated. Responsiveness to change was assessed in patients 1 year after onset of type 1 diabetes and following a structured education program.

RESULTS

The SCI-R presented good internal reliability Cronbach's α: 0.75, test-retest reliability (r = 0.82) and structural validity (r > 0.40). The external validity was also good; the SCI-R correlated with HbA1c in patients with type 1 diabetes on multiple insulin doses (r = -0.50) or continuous subcutaneous insulin infusion (r = -0.66) and in patients with type 2 diabetes on multiple insulin doses (r = -0.62). However, it was not satisfactory in patients on oral agents (r = -0.20) and/or bedtime insulin (r = -0.35). Responsiveness to change was analyzed in 54 patients (age 27.3±7.4 years, 26% men, HbA1c 6.8% ±1.1%); the SCI-R score was 72.3% ±13.7% and correlated negatively with glycated hemoglobin (r = -0.42) and 3 scales of the Diabetes Quality of Life questionnaire (lower score indicating better perception): Impact (r = -0.37), Social Worry (r = -0.36) and Diabetes Worry (r = -0.38), all at P < 0.05.

CONCLUSION

The Spanish and Catalan versions of the SCI-R questionnaire show good psychometric properties and both could be considered as useful tools for evaluating self-care behavior in patients with type 1 or type 2 diabetes. However, there are still some subgroups of patients with type 2 diabetes in which the validity of this questionnaire needs further evaluation.

Hypoglycaemia and cardiovascular disease in Type 1 Diabetes. Results from the Catalan National Public Health registry on insulin pump therapy

Severe hypoglycaemia has recently been associated with an increased risk for cardiovascular disease (CVD) in diabetes. The retrospective analysis of a national registry on continuous subcutaneous insulin infusion points to a higher prevalence of CVD in Type 1 diabetic subjects with repeated severe hypoglycaemia at the time of starting CSII.

Preclinical arterial disease in patients with type 1 diabetes without other major cardiovascular risk factors or micro-/ macrovascular disease

We aimed to investigate preclinical atherosclerosis in T1D and its relationship with glucose profile and endothelial/ inflammatory markers. Thirty-eight T1D patients without additional cardiovascular risk factors or micro-/macrovascular complications and 22 healthy matched subjects were included. FMD and cIMT/fIMT were performed in addition to 72-h continuous glucose monitoring and the measurement of endothelial/inflammatory markers. Lower FMD percentages and greater cIMT/fIMT were observed in patients with T1D in comparison with controls (FMD 7.0 ± 3.1% vs. 9.6 ± 2.2%; p<0.005; cIMT 0.523 ± 0.091 mm vs. 0.471 ± 0.061 mm; p<0.05 and fIMT 0.512 ± 0.172 mm vs. 0.394 ± 0.061 mm; p<0.01, for patients and controls, respectively). T1D subjects in the highest tertile of cIMT were older than those in the lowest group (39.9 ± 9.5 vs. 29.6 ± 4.7 years; p<0.005) and had a longer duration of the disease (18.7 ± 5.4 years vs. 11.8 ± 6.4 years). The higher the cIMT tertile, the greater the fIMT (0.397 ± 0.114 mm vs. 0.431 ± 0.082 mm vs. 0.583 ± 0.197 mm; p<0.05). MAGE was negatively correlated to FMD (r=-0.328; p<0.05) and positively to cIMT (r=0.322; p<0.05). There were no differences between cIMT tertiles in terms of metabolic parameters or endothelial and inflammatory markers. Signals of preclinical atherosclerosis in T1D even in the absence of cardiovascular risk factors and micro- / macrovascular disease are reported. Our findings suggest that daily glucose instability could negatively impact vascular function and structure.

Repeated episodes of hypoglycemia as a potential aggravating factor for preclinical atherosclerosis in subjects with type 1 diabetes

OBJECTIVE

To evaluate through early preclinical atherosclerosis assessment whether repeated episodes of hypoglycemia represent an aggravating factor for macrovascular disease in type 1 diabetes.

RESEARCH DESIGN AND METHODS

After sample-size calculation, a case-control study of 25 patients with type 1 diabetes and repeated severe/nonsevere hypoglycemia (H-group) compared with 20 age- and sex-matched type 1 diabetes control subjects (C-group) was designed. Assessment of preclinical atherosclerosis consisted of flow-mediated brachial dilatation (FMD) and carotid and femoral intima-media thickness (IMT) studies. To consider hypoglycemia awareness, two different questionnaires and symptomatic response to an acute induction to hypoglycemia were used. Evaluation of the glycemic profile was obtained from continuous glucose monitoring. Endothelial function/inflammation markers were measured in euglycemia/hypoglycemia. A multivariate linear regression analysis was performed to test whether repeated hypoglycemia was independently associated with atherosclerosis.

RESULTS

H-group subjects displayed hypoglycemia unawareness and presented a higher percentage of continuous glucose values and area under the curve <70 mg/dl compared with the C-group (14.2 ± 8.9 vs. 6.3 ± 7.1%, P < 0.02 and 2.4 ± 1.8 vs. 0.6 ± 1.0 mg/dl/day, P < 0.01). The percentage of maximal FMD was lower in the H-group than in the C-group (6.52 ± 2.92 vs. 8.62 ± 3.13%, P < 0.05). A significantly higher IMT was observed at both carotid and femoral sites in the H-group (carotid 0.53 ± 0.09 vs. 0.47 ± 0.08 mm, P < 0.05 and femoral 0.51 ± 0.17 vs. 0.39 ± 0.09 mm, P < 0.05). Baseline inflammation and endothelial function markers were higher in the H-group (leukocytes 7.0 ± 1.8 vs. 5.6 ± 1.4 × 10³/ml, von Willebrand factor 119 ± 29 vs. 93 ± 26%, fibrinogen 2.82 ± 0.64 vs. 2.29 ± 0.44 g/l, and soluble intercellular adhesion molecule-1 408 ± 224 vs. 296 ± 95 ng/ml; P < 0.05 for all).

CONCLUSIONS

In addition to the induction of hypoglycemia unawareness and an increased risk for severe hypoglycemia, repeated hypoglycemia could be related to and considered an aggravating factor for preclinical atherosclerosis in type 1 diabetes. The precise mechanisms explaining this association remain to be clarified.

The SWITCH study (sensing with insulin pump therapy to control HbA(1c)): design and methods of a randomized controlled crossover trial on sensor-augmented insulin pump efficacy in type 1 diabetes suboptimally controlled with pump therapy

BACKGROUND

studies investigating the effect of real-time continuous glucose monitoring (CGM) combined with pump therapy on glycemic outcomes in type 1 diabetes are increasing. Pump therapy is well established as a "gold standard" for insulin delivery, offering improvements over multiple daily insulin injections. However, there is still a proportion of subjects using continuous subcutaneous insulin infusion in whom goals for metabolic control are far from achieved or benefits of this type of insulin therapy are transient. The SWITCH (Sensing With Insulin pump Therapy to Control HbA(1c) [hemoglobin A1c]) study is a multicenter, randomized, controlled, crossover study to evaluate if adding CGM to experienced pump patients with suboptimal metabolic control will provide additional insight enabling clinical and therapeutic benefit.

METHODS

subjects meeting the inclusion criteria were randomized to Sensor On or Sensor Off arms for 6 months, after a 1-month run-in period. Following a 4-month washout period, the subjects crossed over to the other study arm for 6 months. The primary end point was the between arm difference in HbA(1c) levels. Among others, additional end points include time spent in different glycemic ranges, percentage of patients with HbA(1c) <7%, number of hypoglycemic events, glucose variability parameters, safety outcomes, treatment satisfaction, and quality of life.

RESULTS

recruitment occurred between January 2008 and February 2009. A total of 153 patients were randomized. Study completion is anticipated in July 2010.

CONCLUSIONS

the results will establish if adding CGM to existing, capable, insulin pump users can enable better metabolic control.

Sustained efficacy of continuous subcutaneous insulin infusion in type 1 diabetes subjects with recurrent non-severe and severe hypoglycemia and hypoglycemia unawareness: a pilot study

BACKGROUND

This study evaluated the effect of CSII on hypoglycemia awareness and on glucose profile in type 1 diabetes (T1D) subjects with repeated non-severe or severe hypoglycemia (NS or SH, respectively).

METHODS

We included subjects (1) older than 18 years, (2) with T1D duration of >5 years, (3) on multiple doses of insulin, and (4) without micro- or macrovascular complications and more than four NS events per week (in the last 8 weeks) and more than two SH events (in the last 2 years). NS/SH episodes and hypoglycemia awareness were evaluated. A 72-h continuous glucose monitoring (CGM) was performed before continuous subcutaneous insulin infusion (CSII). A hypoglycemia-induced test was used to evaluate each patient's symptoms in euglycemia/hypoglycemia. Quality of life (QoL) was also evaluated. After 6, 12, and 24 months, all the subjects were reevaluated.

RESULTS

Twenty subjects were included (34.0 +/- 7.5 years old, 12 women, A1c 6.7 +/- 1.1%, 16.2 +/- 6.6 years of diabetes' duration). At baseline, 19 out of 20 subjects displayed hypoglycemia unawareness, which diminished significantly during the follow-up (3 out of 20). NH episodes per week diminished from 5.40 +/- 2.09 at baseline to 2.75 +/- 1.74 at the end of the follow-up (P < 0.001). SH episodes fell from 1.25 +/- 0.44 per subject-year to 0.05 +/- 0.22 after 24 months (P < 0.001). Hemoglobin A1c remained unaltered. With CGM, the percentage of values within 70-180 mg/dL increased (53.2 +/- 11.0% to 60.3 +/- 17.1%, P = 0.13), and the percentage of values <70 mg/dL decreased (13.7 +/- 9.4% to 9.1 +/- 5.2%, P = 0.07), after 24 months. Mean amplitude of glycemic excursions diminished after 24 months of CSII (136 +/- 28 mg/dL to 115 +/- 19 mg/dL; P < 0.02). An improvement in all the aspects of QoL was observed. The basal alteration in symptom response to an induced hypoglycemia improved after 24 months of initiating CSII leading to a response indistiguishable from that observed in a control group of subjects with T1D without repeated NH and SH.

CONCLUSIONS

CSII prevents hypoglycemic episodes, improves hypoglycemia awareness, and ameliorates glycemic profile in T1D subjects with repeated NS/SH. Its use is also associated with an improvement in diabetes QoL.

[Axillary recurrences after sentinel lymph node biopsy in initial breast cancer]

OBJECTIVE

The aim of our study was to analyze the application of the Selective Sentinel Lymph Node Biopsy (SLNB) in early Breast Cancer of our population, through the analysis of axillary recurrences in patients with false negative sentinel node procedures without complete axillary lymphadenectomy, after a subsequent clinical follow-up.

MATERIAL AND METHODS

A total of 218 early Breast Cancer patients who underwent SLNB after being diagnosed of early breast cancer (T1-2N0) with complete axillary dissection only when the SLNB was positive in the histopathological analysis. In every case, a 2-day protocol was used to localize the sentinel node after injection of (⁹⁹m)Tc-Nanocolloid.

RESULTS

The mean subsequent clinical follow-up was 27 months. A total of 413 sentinel nodes were removed with a median of 1.89/p (range 1-5). Infiltration was detected in 33.9% of patients (59.45% macrometastasis, 22.97% micrometastasis and 17.5% Isolated Tumor Cells (ITC)) and negative for the other nodes excised after conventional lymphadenectomy in 60% of cases. In our population, there was only one case of false negative (FN) SLN due to massive lymphatic blockage, and an abnormal lymph node without uptake adjacent to the SLN was identified intraoperatively. No case of axillary recurrence was detected during an average follow-up of 27 months.

CONCLUSION

The absence of axillary recurrences in our population with negative SLNB without complete axillary dissection demonstrates the appropriate local control offered by this procedure in early Breast Cancer.

Glycaemic profile characteristics and frequency of impaired awareness of hypoglycaemia in subjects with T1D and repeated hypoglycaemic events

The aim of our study was to evaluate the frequency of hypoglycaemia unawareness and the continuous glucose profile in a group of subjects with Type 1 diabetes (T1D) with repeated non-severe/severe hypoglycaemia. Twenty patients (aged 35.2 +/- 7.6 years, duration of disease 16.4 +/- 6.4 years) were included. Hypoglycaemia awareness was evaluated using questionnaires and after an acute-induced hypoglycaemia. Glucose profile was studied using 72-h continuous glucose monitoring (CGM). All subjects were classified as having hypoglycaemia unawareness by questionnaires. Four patients displayed a "normal" signs/symptoms response to hypoglycaemia. The CGM revealed 18% of the measurements <70 mg/dl and this percentage was correlated with questionnaire score (r = 0.55, P < 0.035) and with the increase in the percentage of signs/symptoms during the induced hypoglycaemia (r = -0.57, P < 0.015). In patients exhibiting an "abnormal" response during hypoglycaemia, CGM values <70 mg/dl was higher (22.6 +/- 8.4%) than in those with a "normal" response (10.2 +/- 9.0%; P < 0.028). Summarising, in subjects with T1D and repeated hypoglycaemia the frequency of impaired awareness is substantially common. Its presence is related to a high proportion of ambulatory glycaemic profile below the desirable range.

Performance of VITEK-2 Compact and overnight MicroScan panels for direct identification and susceptibility testing of Gram-negative bacilli from positive FAN BacT/ALERT blood culture bottles

We describe the reliability of the VITEK-2 Compact and overnight MicroScan panels for direct identification and susceptibility testing from the BacT/ALERT blood culture system when using FAN (FA and FN) bottles. A simple procedure, in two centrifugation steps, was designed to remove the charcoal particles present in FA and FN bottles. A total of 113 positive blood cultures showing Gram-negative rods were investigated. Enterobacteriaceae were isolated in 104 cases, and Pseudomonas aeruginosa in nine. The MicroScan system correctly identified 106 (93.8%) of the 113 isolates. The seven identificaction errors included P. aeruginosa (three), Enterobacter cloacae (one), Escherichia coli (one), Klebsiella oxytoca (one), and Klebsiella pneumoniae (one). The VITEK-2 system correctly identified 109 (96.5%) of the 113 samples obtained directly from the blood culture bottles. The four unidentified isolates were Enterobacter cloacae (two), Escherichia coli (one), and P. aeruginosa (one). MicroScan yielded 4/779 (0.5%) very major errors and 28/2825 (0.9%) minor errors. VITEK-2 yielded 2/550 (0.36%) very major errors, 1/1718 (0.05%) major error, and 32/2373 (1.3%) minor errors. Both systems provided excellent identification (correlation of >90%) and susceptibility (correlation of >98%) results. The average times required to obtain identification and susceptibility results using the direct test applied to the VITEK-2 Compact system were 4.57 +/- 1.37 h and 6.52 +/- 1.64 h, respectively. The VITEK-2 compact system provided results on the same day that the blood culture was found to be positive.

Phenotype changes at the onset of type 1 diabetes in young adults from a mediterranean area throughout the last decade

The Accelerator hypothesis postulates that Type 1 Diabetes (T1D) and Type 2 Diabetes are mostly the same disorder. Till now, the data testing the hypothesis and the importance of BMI and insulin resistance in the development of T1D comes almost exclusively from childhood. Our study aimed to investigate changes in clinical and metabolic characteristics of young adults at diagnosis of T1D during the last decade in a Mediterranean area. Ninety-three adults (> or =18 years) with newly diagnosed T1D were evaluated from our database. Thirty-one of them were diagnosed in the period 07/1994-1995 (G95), 39 between 07/1998 and 1999 (G99) and 23 in 2003 (G03). Plasma C-peptide measurements were performed before and 6 min after intravenous injection of 1 mg of glucagon. In those subjects with a basal C-peptide > 0.2 nmol/l, insulin resistance was evaluated using the HOMA-2 model. HbAc, GAD, IA2 and insulin autoantibodies were measured. There was not a significant rise in BMI at diagnosis of T1D in young adults admitted to our Hospital. This was also the case when BMI after 4 weeks of diagnosis was considered (23.7 +/- 3.6, 23,6 +/- 2.4 and 23.4 +/- 3.3 kg/m2, G95 G99 and G03, respectively). In the entire group of subjects, we could not observed any relationship between the patients BMI and age at diagnosis. Likewise, we could not observed differences in any of the clinical, immunological or metabolic characteristics. IR was not different between groups (G95 n=18, 0.73 +/- 0.21; G99 n=29, 0.86 +/- 0.33; G3 n=13, 0.66 +/- 0.34) and was not related to the age at diagnosis. In summary, our data collected from young adults with newly diagnosed T1D from a Mediterranean area indicates that the phenotype, including BMI, at the onset of the disease has not substantially varied during the last decade. In spite of our data do not fit with the accelerator hypothesis the postulate could be of interest in a different age group.

Efficacy of continuous subcutaneous insulin infusion in Type 1 diabetes: a 2-year perspective using the established criteria for funding from a National Health Service

AIM

To determine the 2-year efficacy of continuous subcutaneous insulin infusion (CSII) following the current established criteria for funding of a National Health Service.

METHODS

Longitudinal, prospective, observational unicentre study. Included in the study were 153 Type 1 diabetes (T1D) subjects, previously treated with multiple daily injections (MDI) of insulin, in whom CSII was started in accordance with the criteria for reimbursement of the Catalan National Health Service. At baseline, we recorded data on age, gender, duration of the disease, body mass index (BMI), insulin dose and indications for CSII. Glycated haemoglobin (HbA(1c)) and the frequency of hypoglycaemic events were used to assess glycaemic control. Quality of life was assessed using three different self-report questionnaires. After 24 months, these same items were remeasured in all subjects. Serious adverse events and injection-site complications were also recorded.

RESULTS

In 96% of subjects, CSII indication included less than optimal glycaemic control using MDI. HbA(1c) fell from 7.9 +/- 1.3 to 7.3 +/- 1.1% (P < or = 0.001) after 24 months of CSII. Insulin requirements were significantly lower at the end of follow-up (0.55 +/- 0.21 U/kg body weight) in comparison with before use of CSII (0.70 +/- 0.20, P < or = 0.001). BMI increased from 24.0 +/- 3.1 to 24.4 +/- 3.2 kg/m(2) after 24 months (P < or = 0.025). The rate of episodes of diabetic ketoacidosis per year remained unchanged. Mild and severe hypoglycaemic episodes were significantly reduced. The scores in all subsets of the Diabetes Quality-of-Life (DQoL) questionnaire significantly improved after 24 months of CSII.

CONCLUSIONS

CSII, commenced according to the criteria for a nationally funded clinical programme, improves glycaemic control and quality-of-life outcomes with fewer hypoglycaemic episodes in T1D subjects previously conventionally treated with MDI.

Cerebral atrophy in Parkinson's disease patients with visual hallucinations

Although visual hallucinations (VH) are relatively frequent in Parkinson's disease (PD) patients, their neural substrates are only known from neuropathological and functional magnetic resonance studies. The aim of this study was to investigate possible structural brain changes on MRI in non-demented PD patients with VH using voxel-based morphometry. Eighteen PD patients with VH were compared to 20 patients with PD without VH and 21 healthy controls. Compared with both controls and the non-hallucinating PD group, PD patients with VH had grey matter volume reductions in the lingual gyrus and superior parietal lobe. Structural changes in these areas involved in higher visual processing may be important in understanding the VH and visual deficits in PD patients.

Outcome of pregnancy in women with type 1 diabetes intensively treated with continuous subcutaneous insulin infusion or conventional therapy. A case-control study

The aim was to evaluate and compare the outcome of pregnancies of women with type 1 diabetes (T1D) intensively treated with continuous subcutaneous insulin infusion (CSII) or multiple daily injections (MDI). Twenty-nine women with T1D receiving CSII during pregnancy as intensive insulin therapy (27 started CSII during pregnancy planning while 2 started CSII during the 1st month of gestation) were matched for age, duration of T1D, White's classification, BMI before gestation, parity and HbA1c before pregnancy with 29 women treated with MDI. Metabolic control and acute complications were registered including ketoacidosis and severe hypoglycaemic episodes, and the development of hypertension induced by pregnancy and pre-eclampsia. Perinatal mortality, stillbirth, minor and major congenital malformations, macrosomia, weeks at delivery, caesarean section and perinatal complications were also recorded. As expected, there were no differences between the two groups in terms of age, duration of the disease, White's classification, BMI before gestation, parity and HbA1c before pregnancy. The proportion of subjects who received preconceptional guidance and planned pregnancy did not differ between groups. No differences were observed in HbA1c, insulin dose and BMI throughout gestation in either group of patients. Maternal, foetal and perinatal outcome were similar in women treated with CSII or MDI. The use of CSII in pregestational T1D women is associated with similar results in metabolic control, maternal, foetal and perinatal outcome during pregnancy to those obtained using MDI.

Performance tests of two portable mini gamma cameras for medical applications

We have developed two prototypes of portable gamma cameras for medical applications based on a previous prototype designed and tested by our group. These cameras use a CsI(Na) continuous scintillation crystal coupled to the new flat-panel-type multianode position-sensitive photomultiplier tube, H8500 from Hamamatsu Photonics. One of the prototypes, mainly intended for intrasurgical use, has a field of view of 44 x 44 mm2, and weighs 1.2 kg. Its intrinsic resolution is better than 1.5 mm and its energy resolution is about 13% at 140 keV. The second prototype, mainly intended for osteological, renal, mammary, and endocrine (thyroid, parathyroid, and suprarenal) scintigraphies, weighs a total of 2 kg. Its average spatial resolution is 2 mm; it has a field of view of 95 x 95 mm2, with an energy resolution of about 15% at 140 keV. The main advantages of these gamma camera prototypes with respect to those previously reported in the literature are high portability and low weight, with no significant loss of sensitivity and spatial resolution. All the electronic components are packed inside the mini gamma cameras, and no external electronic devices are required. The cameras are only connected through the universal serial bus port to a portable PC. In this paper, we present the design of the cameras and describe the procedures that have led us to choose their configuration together with the most important performance features of the cameras. For one of the prototypes, clinical tests on melanoma patients are presented and images are compared with those obtained with a conventional camera.

Memory Performance in a Sample of Very Low Birth Weight Adolescents

Prematurely born participants with very low birth weight (VLBW) are at high risk of brain injury in the perinatal period and of later cognitive impairment. Studies of long-term memory sequelae in VLBW participants are scarce and focus on verbal and visual memory assessed by standard clinical memory tests. There is even less research into everyday memory, and the results obtained are contradictory. This study explores long-term memory deficits in VLBW adolescents using 2 standard clinical memory tests and 1 everyday memory test. Results show impairment only in everyday memory. These memory deficits are not specific; they are related to an impaired general cognitive performance. Unlike birth weight, gestational age is a good predictor of intelligence.