Continuous glucose monitoring for hypoglycaemia in children: Perspectives in 2020

Hypoglycaemia in children is a major risk factor for adverse neurodevelopment with rates as high as 50% in hyperinsulinaemic hypoglycaemia (HH). A key part of management relies upon timely identification and treatment of hypoglycaemia. The current standard of care for glucose monitoring is by infrequent fingerprick plasma glucose testing but this carries a high risk of missed hypoglycaemia identification. High-frequency Continuous Glucose Monitoring (CGM) offers an attractive alternative for glucose trend monitoring and glycaemic phenotyping but its utility remains largely unestablished in disorders of hypoglycaemia. Attempts to determine accuracy through correlation with plasma glucose measurements using conventional methods such as Mean Absolute Relative Difference (MARD) overestimate accuracy at hypoglycaemia. The inaccuracy of CGM in true hypoglycaemia is amplified by calibration algorithms that prioritize hyperglycaemia over hypoglycaemia with minimal objective evidence of efficacy in HH. Conversely, alternative algorithm design has significant potential for predicting hypoglycaemia to prevent neuroglycopaenia and consequent brain dysfunction in childhood disorders. Delays in the detection of hypoglycaemia, alarm fatigue, device calibration and current high cost are all barriers to the wider adoption of CGM in disorders of hypoglycaemia. However, machine learning, artificial intelligence and other computer-generated algorithms now offer significant potential for further improvement in CGM device technology and widespread application in childhood hypoglycaemia.

Complexities in the medical management of hypoglycaemia due to congenital hyperinsulinism

Congenital Hyperinsulinism (CHI) is a rare disease of hypoglycaemia but is the most common form of recurrent and severe hypoglycaemia causing brain injury and neurodisability in children. The management of CHI is complex due to the limited choice of medications, all with a limited therapeutic window, often lacking efficacy and associated with serious side effects. The therapeutic strategy in CHI is to recognize and treat hypoglycaemia promptly, thereby optimizing long-term neurological outcomes; this should be achieved through individualized treatment plans that deliver glycaemic stability while minimizing side effects. Further, such a strategy should consider the likelihood of reduction in disease severity over time, with dose adjustments and medication withdrawal as indicated to optimize both safety and tolerability. The option for pancreatic surgery should also be considered in specific circumstances as appropriate for the patient's best long-term interests.

Adverse childhood experiences: association with physical and mental health conditions among older adults in Bhutan

OBJECTIVES

Adverse childhood experiences (ACEs) are events stressful, traumatic, and related to the development of a wide range of health conditions throughout the person's lifespan. This study explored the relationship between ACEs and health conditions among older adults in Bhutan.

STUDY DESIGN

Cross-sectional survey.

METHODS

Older adults aged 60-101 years (n = 337) completed a face-to-face interview in a convenient community setting in the four major towns of Bhutan. Measurements included the modified World Health Organization Adverse Childhood Experiences International Questionnaire and the checklist of chronic health conditions.

RESULTS

Commonest ACEs reported by the sample were related to the contribution of physical labour in childhood (n = 284 [84.3%]) and witnessing of community violence (n = 185 [54.9%]). Assuming an adult role while still a child highly co-occur with other forms of ACEs. Compared to 0-2 ACEs, participants with ≥7 ACEs had the higher odds of reporting lung disease (odds ratio [OR] = 2.15, 95% confidence interval [CI]: 1.03-4.49), visual impairment (OR = 2.38, 95%CI: 1.16-4.85), insomnia (OR = 2.35, 95%CI: 1.11-4.98), and memory decline (OR = 2.30, 95%CI: 1.10-4.78) by twofold and high blood pressure by threefold (OR = 3.21, 95%CI: 1.39-7.38). Overall, the odds of self-rated poor health conditions among those ≥7 ACEs compared to 0-2 ACEs was high by almost twofold (OR = 1.97; 95%CI: 1.04-3.73).

CONCLUSIONS

The influence of ACEs on health conditions persisted into late adulthood, and older people in Bhutan have had a complex variety of chronic health conditions implicating greater demand on the free healthcare system in Bhutan. ACEs prevention is critical to promote better health for a country like Bhutan, where the healthcare services are provided free of cost to its citizens.

Delayed Resolution of Feeding Problems in Patients With Congenital Hyperinsulinism

Background: Congenital Hyperinsulinism (CHI) is the most common cause of recurrent and severe hypoglycaemia in childhood. Feeding problems occur frequently in severe CHI but long-term persistence and rates of resolution have not been described. Methods: All patients with CHI admitted to a specialist center during 2015-2016 were assessed for feeding problems at hospital admission and for three years following discharge, through a combination of specialist speech and language therapy review and parent-report at clinical contact. Results: Twenty-five patients (18% of all patients admitted) with CHI were prospectively identified to have feeding problems related to sucking (n = 6), swallowing (n = 2), vomiting (n = 20), and feed aversion (n = 17) at the time of diagnosis. Sixteen (64%) patients required feeding support by nasogastric/gastrostomy tubes at diagnosis; tube feeding reduced to 4 (16%) patients by one year and 3 (12%) patients by three years. Feed aversion resolved slowly with mean time to resolution of 240 days after discharge; in 15 patients followed up for three years, 6 (24%) continued to report aversion. The mean time (days) to resolution of feeding problems was lower in those who underwent lesionectomy (n = 4) than in those who did not (30 vs. 590, p = 0.009) and significance persisted after adjustment for associated factors (p = 0.015). Conclusion: Feeding problems, particularly feed aversion, are frequent in patients with CHI and require support over several years. By contrast, feeding problems resolve rapidly in patients with focal CHI undergoing curative lesionectomy, suggesting the association of feeding problems with hyperinsulinism.

Central venous catheter-associated thrombosis in children with congenital hyperinsulinism

Congenital hyperinsulinism (CHI) is an important cause of severe hypoglycaemia in infancy. To correct hypoglycaemia, high concentrations of dextrose are often required through a central venous catheter (CVC) with consequent risk of thrombosis. We describe a series of six cases of CHI due to varying aetiologies from our centre requiring CVC for the management of hypoglycaemia, who developed thrombosis in association with CVC. We subsequently analysed the incidence and risk factors for CVC-associated thrombosis, as well as the outcomes of enoxaparin prophylaxis. The six cases occurred over a 3-year period; we identified an additional 27 patients with CHI who required CVC insertion during this period (n = 33 total), and a separate cohort of patients with CHI and CVC who received enoxaparin prophylaxis (n = 7). The incidence of CVC-associated thrombosis was 18% (6/33) over the 3 years, a rate of 4.2 thromboses/1000 CVC days. There was no difference in the frequency of genetic mutations or focal CHI in those that developed thromboses. However, compound heterozygous/homozygous potassium ATP channel mutations correlated with thrombosis (R² = 0.40, P = 0.001). No difference was observed in CVC duration, high concentration dextrose or glucagon infused through the CVC. In patients receiving enoxaparin prophylaxis, none developed thrombosis or bleeding complications. The characteristics of these patients did not differ significantly from those with thrombosis not on prophylaxis. We therefore conclude that CVC-associated thrombosis can occur in a significant proportion (18%) of patients with CHI, particularly in severe CHI, for which anticoagulant prophylaxis may be indicated.

Observations of core ion cyclotron emission on ASDEX Upgrade tokamak

The B-dot probe diagnostic suite on the ASDEX Upgrade tokamak has recently been upgraded with a new 125 MHz, 14 bit resolution digitizer to study ion cyclotron emission (ICE). While classic edge emission from the low field side plasma is often observed, we also measure waves originating from the core with fast fusion protons or beam injected deuterons being a possible emission driver. Comparing the measured frequency values with ion cyclotron harmonics present in the plasma places the origin of this emission on the magnetic axis, with the fundamental hydrogen/second deuterium cyclotron harmonic matching the observed values. The actual values range from ∼27 MHz at the on-axis toroidal field B_T = -1.79 T to ∼40 MHz at B_T = -2.62 T. When the magnetic axis position evolves during this emission, the measured frequency values track the changes in the estimated on-axis cyclotron frequency values. Core ICE is usually a transient event lasting ∼100 ms during the neutral beam startup phase. However, in some cases, core emission occurs in steady-state plasmas and lasts for longer than 1 s. These observations suggest an attractive possibility of using a non-perturbing ICE-based diagnostic to passively monitor fusion alpha particles at the location of their birth in the plasma core, in deuterium-tritium burning devices such as ITER and DEMO.

(ICORG 05-03): prospective randomized non-inferiority phase III trial comparing two radiation schedules in malignant spinal cord compression (not proceeding with surgical decompression); the quality of life analysis

BACKGROUND

The optimal primary external beam radiation therapy (EBRT) radiation schedule for malignant epidural spinal cord compression (MSCC) remains to be determined. The ICORG 05-03 trial assessed if a 10 Gy single fraction radiation schedule was not inferior to one with 20 Gray (Gy) in five daily fractions, in terms of functional motor outcome, for the treatment of MSCC in patients not proceeding with surgical decompression. This article reports on two of the secondary endpoints, Quality of life (QoL), assessed according to the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire Core 30 (QLQ-C30) version 3.0 (EORTC Data Center, Brussels, Belgium) and pain control assessed using a visual analog scale.

METHODS

A randomized, parallel group, multicenter phase III trial was conducted by Cancer Trials Ireland (formerly All-Ireland Cooperative Oncology Research Group, ICORG), across five hospital sites in Ireland and Northern Ireland. Patients were randomized to 10 Gy single fraction of EBRT or 20 Gy in five fractions in a 1:1 ratio. Patients with baseline and 5-week follow up QoL data are included in this analysis.

FINDINGS

From 2006 to 2014, 112 eligible patients were enrolled for whom 57 were evaluated for this secondary analysis. After adjusting for pre-intervention scores, there was no statistically significant difference in post-treatment Summary scores (excl. FI and QL), or pain scores between the two RT schedules at 5 weeks and 3 months following EBRT. There was a statistically significant relationship between the pretreatment and post-treatment Summary scores (p =  .002) but not between the pre-treatment and post-treatment pain scores.

INTERPRETATION

Primary radiotherapy for the treatment of MSCC significantly improves QoL in patients not proceeding with surgical decompression. After adjusting for pre-intervention scores, there was no statistically significant difference between a 10 Gy single fraction radiation schedule and one with 20 Gy in five daily fractions on post-treatment QoL Summary scores. For most patients, an effective treatment with low burden would be desirable. A single fraction schedule should be considered for this group of patients.

Field-Line Localized Destabilization of Ballooning Modes in Three-Dimensional Tokamaks

Field-line localized ballooning modes have been observed at the edge of high confinement mode plasmas in ASDEX Upgrade with rotating 3D perturbations induced by an externally applied n=2 error field and during a moderate level of edge localized mode mitigation. The observed ballooning modes are localized to the field lines which experience one of the two zero crossings of the radial flux surface displacement during one rotation period. The localization of the ballooning modes agrees very well with the localization of the largest growth rates from infinite-n ideal ballooning stability calculations using a realistic 3D ideal magnetohydrodynamic equilibrium. This analysis predicts a lower stability with respect to the axisymmetric case. The primary mechanism for the local lower stability is the 3D distortion of the local magnetic shear.

Influence of non-local thermodynamic equilibrium and Zeeman effects on magnetic equilibrium reconstruction using spectral motional Stark effect diagnostic

The Motional Stark Effect (MSE) diagnostic is a well established technique to infer the local internal magnetic field in fusion plasmas. In this paper, the existing forward model which describes the MSE data is extended by the Zeeman effect, fine-structure, and relativistic corrections in the interpretation of the MSE spectra for different experimental conditions at the tokamak ASDEX Upgrade. The contribution of the non-Local Thermodynamic Equilibrium (non-LTE) populations among the magnetic sub-levels and the Zeeman effect on the derived plasma parameters is different. The obtained pitch angle is changed by 3°…4° and by 0.5°…1° including the non-LTE and the Zeeman effects into the standard statistical MSE model. The total correction is about 4°. Moreover, the variation of the magnetic field strength is significantly changed by 2.2% due to the Zeeman effect only. While the data on the derived pitch angle still could not be tested against the other diagnostics, the results from an equilibrium reconstruction solver confirm the obtained values for magnetic field strength.

Extensions to the charge exchange recombination spectroscopy diagnostic suite at ASDEX Upgrade

A new core charge exchange recombination spectroscopy diagnostic has been installed in the ASDEX Upgrade tokamak that is capable of measuring the impurity ion temperature, toroidal rotation, and density on both the low field side (LFS) and high field side (HFS) of the plasma. The new system features 48 lines-of-sight (LOS) with a radial resolution that varies from ±2 cm on the LFS down to ±0.75 cm on the HFS and has sufficient signal to run routinely at 10 ms and for special circumstances down to 2.5 ms integration time. The LFS-HFS ion temperature profiles provide an additional constraint on the magnetic equilibrium reconstruction, and the toroidal rotation frequency profiles are of sufficiently high quality that information on the poloidal velocity can be extracted from the LFS-HFS asymmetry. The diagnostic LOS are coupled to two flexible-wavelength spectrometers such that complete LFS-HFS profiles from two separate impurities can be imaged simultaneously, albeit with reduced radial coverage. More frequently, the systems measure the same impurity providing very detailed information on the chosen species. Care has been taken to calibrate the systems as accurately as possible and to include in the data analysis any effects that could lead to spurious temperatures or rotations.